Hormone replacement therapy

In the form of systemic oestrogen therapy (e.g. patches, gels and oral preparations), this is the most effective treatment for the relief of menopausal hot flushes and night sweats. If these are particularly troublesome, suggest referral to the patient’s primary care practice for this treatment. Many practices will have a nurse (or pharmacist), skilled at managing the menopause and prescribing HRT.

Treatment for up to five years to help with menopausal symptoms is very safe for most women. Women who have a uterus must be co-prescribed progestogen as unopposed oestrogen can cause endometrial cancer. Some women on systemic HRT may also benefit from additional low dose vaginal oestrogen.

There has been considerable concern in recent years about the safety of HRT, particularly about increasing the risk of breast cancer. This has led to some GPs being unwilling to prescribe it.

Some of this concern may have arisen out of historical inappropriate long-term use in older women (for 10 years or more) where HRT was purported to be an anti-ageing intervention, and for use to prevent or treat osteoporosis. These ‘off label’ uses are no longer advocated and the MHRA specifically advises that HRT should not be used for osteoporosis, apart from in exceptional circumstances.

HRT may be used in the context of early menopause (i.e. before 45 years) for longer periods of time (up to age 50 years or so) and the benefits of this are greater than the potential risks.

Absolute contraindications for HRT are very  few and include breast cancer, endometrial cancer, undiagnosed vaginal bleeding and active liver disease. A history of venous thromboembolism (VTE) is a relative contraindication and may require specialist input if HRT is considered necessary. NICE advises that transdermal HRT products may be safer in cases of high VTE risk.