Menopause and HRT

What are the symptoms of the menopause❓ 

 Hot flushes πŸ˜°

 Night sweats πŸ’€

 Mood changes (low mood/anxiety) 

 Difficulty/disturbances sleeping πŸ’€

 Cognitive disturbances (memory loss/difficulty concentrating) 

 Libido loss (sex drive) 

 Irregular menstruation 

 Dry vagina  

 Urination problems πŸ’§

 Aches and pains of joints/muscles 


How is the menopause diagnosed❓ 

  1. Usually based on the clinical symptoms & age; but beware the following;
  2. Abnormal bleeding needs investigating 
  3. Consider differential diagnosis 
  4. Arrange Follicle Stimulating Hormone for patients if: 
  5. < 40: premature menopause (2 separate results, > 30 IU/L, between 4 and 8 weeks apart) 
  6. < 45: early menopause (2 separate results, >30 IU/L, between 4 and 8 weeks apart) 
  7. > 50: wants to stop taking hormonal contraception (1 > 30 IU/L result – patient can stop taking hormonal contraception in 12 months) 


How is the menopause treated❓ 

Lifestyle changes: 

 Regular exercise πŸš΄

 Relaxation exercise 

 Stress reduction β¬‡ 

 Decrease alcohol intake 

 Smoking cessation πŸš¬

 Healthy BMI 

 Improve sleep hygiene πŸ’€

 Avoid vasomotor symptoms (e.g. spicy food) 

HRT (Hormone Replacement Therapy): 

 Fist line therapy for low mood and vasomotor symptoms 

 Also beneficial for musculoskeletal symptoms, low sex drive, bone mineral density and urogenital atrophy 

HRT alternative options: 

 CBT – beneficial for low mood and anxiety symptoms πŸ˜’

 Isoflavones – can be beneficial for hot flushes πŸ˜°

 Avoid SSRIs, SNRIs and clonidine as first line therapy 


Are there any contraindications to HRT❓ 

 History of breast cancer or oestrogen-rich tumour 

 Bleeding of vagina which is undiagnosed 

 Arterial thromboembolic disease 


 Endometrial hyperplasia which is untreated 

 Current/recurrent VTE 

 Liver disease 


What are the risks of HRT❓ 

Breast cancer:  

 Risk from lifestyle choices likely greater than from HRT πŸš¬

 Greater risk with combined HRT than oestrogen only HRT 

 Micronised progesterone likely safest progestogen 


 Risk increased by HRT β¬† 

 Oral HRT preparations increase risk β¬† 

 Micronised progesterone likely safest progestogen 

CVD (Cardiovascular disease):  

 Post-menopausal women most commonly die of CVD 

In women <65, HRT does NOT increase risk 

 HRT may be cardioprotective in younger women 

Stroke (CVA):  

 Oral HRT increases risk (transdermal HRT preparations are safest) β¬† 

Ovarian Cancer: 

 Risk slightly increased by HRT β¬† 


What are the different types of HRT❓ 



What type of HRT should I offer my patient❓ 


When should I review menopause treatment❓ 

 3 months after you start treatment πŸ“…

 Annually thereafter 


What should I look for when reviewing a patient❓ 

  1. Ask the patient about any side effects, symptoms and indications 
  2. Check patient’s blood pressure, BMI and screening 


What if I identify problems when reviewing a patient❓ 

 Heavy bleeding on sequential HRT – increase progestogen dose/duration 

 Bleeding on combined HRT – if remains after 3 to 6 months of it, try sequential HRT instead 

 Persistent bleeding more than 6 months after starting HRT – investigate the reason for this 

 Side effects caused by progestogen – try alternative progestogen or IUS 


  1. There are many symptoms of menopause which you should be aware of
  2. Menopause is usually diagnosed based on clinical symptoms and age
  3. Treatments: lifestyle changes, HRT or alternatives 
  4. HRT risks: breast cancer, VTE, cardiovascular disease, stroke, ovarian cancer
  5. There are 3 types of HRT: oestrogen only, sequential combined and continuous combined 
  6. You should review treatment 3 months after starting and annually thereafter

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