Menopause: Permanent cessation of monthly menstruation for at least 12 months at the end of reproductive life due to loss of ovarian function. Average age is 51 years (range 45–55). MHT/HRT is sometimes used to treat symptoms of menopause due to estrogen deficiency.
Indications of MHT: Relieving menopause symptoms (hot flushes, night sweats, sleep problems, anxiety, low mood), preventing osteoporosis (maintaining bone health and reducing fractures), reducing risk of coronary heart disease in women <60 within 10 years of menopause, treating genitourinary syndrome of menopause (vaginal dryness, dyspareunia) with vaginal estrogen, and maintaining muscle strength.
Introduction: Covers identifying and managing menopause, including premature ovarian insufficiency. Aims to improve consistency of support and information. Intended for healthcare professionals caring for women with menopause-associated symptoms. Individualized care is essential, tailoring discussions, investigations, and management to symptom changes over time. Discuss symptom management plans, communicate risks, benefits, and consequences, and offer psychological support to early menopause (ages 40–44) patients who are distressed.
Discussing Management Options (≥40 years): Before prescribing HRT, consider benefits and risks of combined vs estrogen-only HRT, transdermal vs oral, types of estrogen and progestogen, sequential vs continuous combined HRT, and dose/duration. Discuss possible treatment duration and review benefits/risks at every review. Explain symptoms may return after stopping HRT and discuss the option of restarting treatment if necessary.
Managing Symptoms: Vasomotor symptoms: offer HRT. Genitourinary symptoms: offer vaginal estrogen (safe even for those on systemic HRT), consider vaginal progesterone if ineffective, or non-hormonal moisturizers/lubricants. Depressive symptoms: consider HRT. Altered sexual function: consider testosterone supplementation if low libido persists despite HRT.
Preparations for MHT:
Estrogen: Most effective for relieving menopausal symptoms. Available orally, transdermally, topically (gels, lotions), intravaginal creams/tablets/rings, and subcutaneous implants in some countries. All routes equally effective for hot flashes; transdermal has lower VTE and stroke risk. Systemic estrogen needed for hot flashes; low-dose vaginal estrogen for genitourinary symptoms. Women with intact uterus must receive progesterone. Estrogen-only HRT for women with total hysterectomy; otherwise increased risk of endometrial hyperplasia and cancer. Slightly increased ovarian cancer risk after 5 years; no increased cardiovascular mortality.
Progestin: Added to protect endometrium in women with uterus. Alternatives for intolerance: levonorgestrel-releasing intrauterine system (LNG-IUS) or conjugated estrogen-bazedoxifene regimen (T SEC).
Other Hormones: Tibolone: synthetic steroid with estrogenic, androgenic, and progestogenic effects. Reduces vasomotor symptoms, improves bone density, modest sexual symptom effect. Increased breast cancer recurrence risk and stroke risk in women >60. Exogenous testosterone improves sexual function in women with low libido.
Dosing and Administration: Standard daily estrogen doses: 17-beta estradiol 1 mg oral or 0.05 mg transdermal. Younger women after bilateral oophorectomy may require higher doses (2 mg oral, 0.1 mg transdermal). Start with lower doses (oral 0.5 mg, transdermal 0.025 mg) and titrate.
Medical History Considerations: Women with Type 2 diabetes: consider HRT. Women with increased VTE risk or BMI >30: prefer transdermal HRT, consider hematology referral. Personal history of CHD or stroke: discuss HRT with menopause specialist. HRT contraindicated in breast cancer history.
Effects on Health Outcomes (≥45 years): Combined HRT recommended for women with uterus. Discuss options to balance benefits/risks. Combined HRT does not affect overall life expectancy. Increases breast cancer risk, decreases endometrial cancer risk with continuous combined HRT, slight ovarian cancer risk increase, does not increase CHD risk, may increase dementia risk if started ≥65 years, reduces fragility fracture risk, unlikely to increase stroke risk, does not increase type 2 diabetes risk. VTE risk increased with oral HRT.
Starting and Stopping HRT: Offer combined HRT for women with uterus, estrogen-only HRT for women post-total hysterectomy. Use lowest effective dosage. Explain vaginal bleeding as common in first 3 months; seek help if occurs after 3 months. Gradual or immediate stopping is acceptable; gradual may limit short-term recurrence of symptoms, but long-term effect similar. Stop systemic HRT in women diagnosed with breast cancer.
Reviewing Treatment: Review at 3 months to assess efficacy and tolerability, then annually unless clinical indications require earlier review. Refer to specialist menopause service if treatment ineffective, side effects occur, contraindications exist, or uncertainty about best option. Initiation of MHT is safe for healthy symptomatic women within 10 years of menopause or younger than 60 without contraindications. MHT not recommended without clear indication. Vaginal estrogen preferred for vaginal atrophy symptoms. MHT effective for hot flashes, vaginal atrophy, and bone loss; not recommended for chronic disease prevention. Estrogen alone increases endometrial hyperplasia/cancer risk; add progesterone if uterus present. Vaginal estrogen may reduce recurrent urinary tract infections. Transdermal preferred over oral in increased VTE risk or BMI. Women with premature ovarian insufficiency or early menopause should continue HRT until natural menopause age.
Compiled By
Dr. Qumrun Nassa Ahmed
Contributors
- Prof Fawzia Hossain
- Prof Maruf Siddique
- Prof KH Shahnewaz
- Dr Fahmida Zesmin
- Dr Lata Dutta
- Dr Sumaiya Binte Asif
- Dr Homaira Naznin
- Dr Mehnaz Tabassum
- Dr Tahia Akhyar Promi
- Dr Reefaat Rahman
- Dr Salma Akter Munmun
- Dr Sabiha Islam
- Dr Shrabanti Mala
- Dr Rowson Ara
- Dr Asma Akter Soma