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Women's Health

Menopause and HRT

Menopause is the transition caused by declining ovarian follicular activity and fluctuating or low oestrogen; diagnose typical cases clinically, then tailor symptom treatment, HRT risks, contraception, bone health and follow-up to the person's stage and comorbidities.

In a nutshell

Diagnose typical perimenopause or menopause clinically in otherwise healthy people aged 45 or over. Offer HRT for vasomotor symptoms when suitable, with combined HRT if a uterus is present and oestrogen-only HRT after total hysterectomy; consider CBT, fezolinetant or other options when HRT is unsuitable, and treat genitourinary symptoms with vaginal oestrogen.

Classic presentation

New hot flushes or sweats with changing periods, followed by amenorrhoea, with possible vaginal dryness, sleep, mood, musculoskeletal or sexual symptoms.

Key points

  • In an otherwise healthy person aged 45 or over, diagnose perimenopause or menopause clinically; do not use a routine FSH or hormone panel.
  • Consider FSH only for people aged 40 to 45 with symptoms and cycle change or for suspected premature ovarian insufficiency under 40; do not use it with combined hormonal contraception or high-dose progestogen.
  • Offer HRT for vasomotor symptoms when suitable: combined HRT with a uterus, oestrogen-only HRT after total hysterectomy, using the lowest effective dose and individualised route and duration.
  • Consider transdermal rather than oral oestrogen with increased VTE risk, and obtain specialist advice for high VTE risk, breast cancer, coronary heart disease or stroke.
  • Offer vaginal oestrogen for genitourinary symptoms, including alongside systemic HRT; absorption is minimal and symptoms may recur when treatment stops.
  • Review treatment at 3 months and annually; investigate bleeding outside the expected early HRT window rather than assuming it is a normal menopause symptom.

First-line investigation

Usually none in a typical presentation over age 45; use targeted tests for alternative diagnoses and FSH only in selected early or atypical presentations.

Management

Diagnose clinically and assess risk

  • Diagnose typical perimenopause or menopause clinically over age 45, assess contraception and alternative causes, and use FSH only for selected early presentations.1,2

Offer HRT when suitable

  • Offer HRT for vasomotor symptoms after shared discussion: combined HRT with a uterus, oestrogen-only HRT after total hysterectomy, and an individualised route, dose and duration.1,4,5

Treat when HRT is unsuitable or declined

  • Consider menopause-specific CBT and current NICE non-hormonal options, including fezolinetant when HRT is unsuitable; do not routinely choose an SSRI, SNRI or clonidine first for vasomotor symptoms alone.1,8

Treat genitourinary symptoms locally

  • Offer vaginal oestrogen, alone or with systemic HRT, and consider non-hormonal moisturisers or lubricants and specialist alternatives when it is unsuitable or ineffective.1,3

Review and safety-net

  • Review treatment at 3 months and annually, and investigate unscheduled bleeding beyond the expected early window, high-risk bleeding, VTE symptoms, breast symptoms or treatment intolerance.1,6,7

Exam traps

  • Do not order FSH routinely for classic symptoms in a person aged 45 or over; perimenopausal hormone levels fluctuate.
  • Unopposed systemic oestrogen is unsafe when a uterus is present; add progestogen for endometrial protection.
  • HRT is not contraception: discuss contraception until menopause is established, particularly in premature ovarian insufficiency or early menopause.
  • Do not routinely use SSRIs, SNRIs or clonidine as first-line treatment for vasomotor symptoms alone; current NICE options include menopause-specific CBT and fezolinetant when HRT is unsuitable.
  • Vaginal oestrogen is local treatment for genitourinary symptoms and can be used with systemic HRT; persistent bleeding still needs assessment.
  • Bleeding beyond the expected early window after starting or changing systemic HRT is not automatically benign and should follow the BMS and NICE pathways.

Illustrations

The hypothalamic-pituitary-ovarian axis in menopauseDiagram showing loss of oestradiol and inhibin negative feedback as follicular activity declines, leading to rising FSH during the menopausal transition.PassFinals · original
Oestrogen-sensitive tissues and menopausal symptomsBody map linking hypothalamic thermoregulation, genitourinary tissues, bone and brain to common menopause-associated symptoms, without implying that every symptom has one cause.PassFinals · original
Individualising HRT choiceDecision diagram showing uterus status, oral versus transdermal route, thrombotic and cancer risk, vaginal symptoms, non-hormonal alternatives and scheduled review.PassFinals · original

Key sources

  1. NICE NG23: Menopause: identification and management (Current NICE guidance for clinical diagnosis, symptom treatment, CBT, vaginal oestrogen, HRT choice, VTE and cancer risk, premature ovarian insufficiency, bleeding and follow-up; last updated 15 April 2026.)
  2. NICE QS143: Menopause quality standard (NICE quality statements supporting symptom-based diagnosis over age 45, FSH assessment in suspected premature ovarian insufficiency and early treatment review.)
  3. British Menopause Society: Genitourinary Syndrome of Menopause consensus statement (Current UK specialist consensus on the chronic, progressive urogenital effects of oestrogen deficiency and local treatment options.)
  4. British Menopause Society: BMS and WHC recommendations on HRT in menopausal women (Updated UK consensus statement on individualised HRT dose, regimen and duration, transdermal route and risk discussion, POI and early menopause.)
  5. BNF online: current HRT and menopause prescribing information (Use the current BNF and local specialist protocol for product selection, licensed indications, contraindications, interactions, doses, monitoring and switching; no fixed dose is reproduced here.)
  6. British Menopause Society and partners: Management of unscheduled bleeding on HRT (UK multidisciplinary guideline for assessment, ultrasound thresholds, urgent assessment and cancer referral in unscheduled bleeding on HRT; published April 2024 and due for review April 2027.)
  7. NICE NG12: Suspected cancer: recognition and referral (Current NICE suspected-cancer pathway used with the BMS HRT-bleeding guideline when postmenopausal or unscheduled bleeding needs urgent endometrial assessment.)
  8. NICE TA1143: Fezolinetant for treating moderate to severe vasomotor symptoms associated with menopause (Current NICE technology appraisal option when HRT is unsuitable, subject to the recommendation, marketing authorisation and current prescribing and monitoring requirements.)
  9. NICE NG101: Early and locally advanced breast cancer (NICE cancer guidance used for the specialist pathway when menopause symptoms or vaginal oestrogen are considered after breast cancer treatment.)
  10. British Menopause Society: HRT before and after a breast-cancer diagnosis (Updated UK specialist consensus on systemic and vaginal hormone treatment after breast cancer and the need for breast-team involvement in higher-risk situations.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.