- Age 45 or over - Diagnosis is clinical and hormone blood tests are not recommended
- Age < 45 - Consider:
- FSH/LH
- Estradiol
- TFT, Prolactin
test announcement
Not recommended for prevention of cardiovascular disease or dementia in absence of menopausal symptoms.
Indications for non-tablet route of Estrogen.
Oral still provides many benefits, convenient, uncomplicated, good bleeding control in continuous combined regimen.
Vaginal estrogen is very effective for urogenital symptoms, several types available, long term treatment recommended https://www.menopausematters.co.uk/local.php
Treatment of urogenital atrophy with vaginal estrogen requires long term treatment. Many women do not realise that the prescription should be continued, and often only receive enough for a few weeks. Some women require vaginal estrogen as well as systemic HRT and they can be used together.
Women having a spontaneous menopause at the usual age, should start on a low dose and only increase gradually (not more often than 3 monthly), if symptoms continue. At a later stage, the dose can gradually be reduced--we have seen several patients in their 60's and 70’s still on a high dose, this is rarely necessary and can cause problems such as bleeding and unnecessary investigations.
Women suffering from a premature or early menopause, often need to gradually increase to fairly high doses of estrogen to control symptoms, especially if a sudden, induced menopause.
In these women, it is reasonable to start at a medium dose and be prepared to increase at 3 monthly intervals.
Ultra low | Low | Medium | High | |
Oral | 0.5mg | 1mg | 2mg | 3mg |
Patch | Half 25mcg | 25mcg | 50mcg | 75-100mcg |
Gel (pump) | Half pump | 1 pump | 2 pumps | 3-4 pumps |
Gel (sachet) | Half 0.5mg sachet | 0.5mg | 1mg | 1.5-2mg |
Advantages of continuous combined include patient satisfaction (most women prefer not to have periods) and better endometrial protection with daily progestogen.
If offering continuous combined, advise that some bleeding within the first 6 months is common and only needs to be investigated if bleeding persists beyond 6 months, or occurs at a later time.
HRT aims to replace estrogen. Unless the patient has had a total hysterectomy, some form of progestogen should be used in addition.Please note:
If Mirena removed and patient has been taking systemic estrogen, HRT MUST be changed to one containing both estrogen andprogestogen and should be clearly documented.
A number of patients are referred having being identified as having had a period of unopposed estrogen. In the absence of abnormal bleeding:
Most common reason for referral is unscheduled bleeding on continuous combined HRT. Bleeding problems can be reduced by
When commenced on HRT or if HRT is changed, review should be arranged after 3 months.
Once settled on HRT or vaginal estrogen, review should be at least annual, to assess effectiveness, presence of side effects, update on new information, help with ongoing risk/benefit analysis.
When to refer depends on your experience and confidence but in general terms, the following apply:
The interactive decision tree on www.menopausematters.co.uk/tree.php aims to help with prescribing decisions.
Telephone helpline, Thursdays 9am to 12, 01387 241121 – run by SR Katrina Martin who is happy to help with any queries and can also be contacted by email at katrina.martin@nhs.scot
Last reviewed: 19/09/2023
Next review date: 19/09/2025
Author(s): Heather Currie.