Key points

All women should be able to access advice on how they can optimise their menopause transition and the years beyond.

There should be a holistic and individualised approach in assessing menopausal women, with particular reference to lifestyle advice, diet modification as well as discussion of the role of HRT.

The decision whether to take HRT, the dose of HRT used and the duration of its use should be made on an individualised basis after discussing the benefits and risks with each patient. This should be considered in the context of the overall benefits obtained from using HRT including symptom control and improving quality of life as well as considering the bone and cardiovascular benefits associated with HRT use.

The HRT dosage, regimen and duration should be individualised, with annual evaluation of advantages and disadvantages.

Transdermal administration of estradiol is unlikely to increase the risk of venous thrombosis or stroke above that in non-users and is associated with a lower risk compared with oral administration of estradiol. The transdermal route should therefore be considered as the first choice route of estradiol administration in women with risk factors.

Evidence from large observational studies and case-controlled studies suggests that micronised progesterone and dydrogesterone are unlikely to increase the risk of venous thrombosis and are associated with a lower risk of breast cancer compared to that noted with oral progestogens.

The potential benefits of bioidentical hormone therapy can be achieved using conventionally licensed products, without having to resort to unregulated compounded varieties from specialist pharmacies.

Arbitrary limits should not be placed on the duration of usage of HRT; if symptoms persist, the benefits of hormone therapy usually outweigh the risks.

HRT prescribed before the age of 60 has a favourable benefit/risk profile.

HRT initiated before the age of 60 or within 10 years of the menopause is likely to be associated with a reduction in coronary heart disease and cardiovascular mortality.

If HRT is to be used in women over 60 years of age, lower doses should be started, preferably with a transdermal route of estradiol administration. Evidence from the Cochrane data-analysis as well as that from the long-term follow-up data of the WHI showed no increase in cardiovascular events, cardiovascular mortality or all-cause mortality in women who initiated HRT more than 10 years after the menopause.

Women with POI and early menopause should be encouraged to use HRT at least until the average age of the menopause.

HRT and the combined contraceptive pill would both be suitable options for hormone replacement in women with POI. However, HRT may result in a more favourable improvement in bone density and cardiovascular markers compared with the combined contraceptive pill.

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Updated: March 2021
Next review date: March 2025