For more information on the menopause, symptoms and diagnosis please visit the ‘Menopause’ page

How is menopause treated?

Lifestyle factors

Regular exercise can be helpful for emotional wellbeing, to improve sleep quality, as well as to build and maintain muscle mass with positive effects on bone health. Reducing alcohol and caffeine intake may help reduce hot flushes. Smoking has been shown to increase risk of early menopause and trigger hot flushes, so stopping smoking can be helpful. Dietary changes can also help with symptoms, such as increasing foods rich in calcium and vitamin D, and reducing sugar intake.

‘Menopausal Hormone Therapy’ (MHT) previously called ‘Hormone Replacement Therapy’ (HRT)

Some women choose not to have hormone-based treatments however, others have troublesome symptoms and choose to have hormonal treatment. Replacement of hormones that would normally have been produced by the ovaries is called ‘Menopausal Hormone Therapy’ (MHT) (previously commonly referred to as ‘Hormone Replacement Therapy’; HRT).

There are many different hormone replacement options but generally all MHT will contain a form of oestrogen and, if needed, a form of progesterone. Progesterone is needed if a woman still has her womb (uterus) present (i.e., she has not had it surgically removed, which is called hysterectomy). This is because oestrogen can stimulate growth of the lining of the womb, and can predispose to the development of abnormal cells (called endometrial hyperplasia), and a small increase in the risk of endometrial cancer. Progesterone helps prevent this risk, and depending on the way progesterone is given, it can lead to bleeding similar to a period. Overall, in women with a uterus, MHT should include progesterone in addition to oestrogen to avoid this risk of endometrial cancer.

MHT can include different hormone components:

• Oestrogen only - suitable for women who do not have a uterus (womb).
• Cyclical combined (oestrogen and progesterone) - in which oestrogen is given continuously and progestogens cyclically and induces a monthly menstrual bleed. This is more frequently used if MHT is started soon after the menopausal transition to avoid breakthrough bleeding but can be continued longer if preferred.
• Continuous combined (oestrogen and progesterone) - preparations in which oestrogen and a progestogen are given together every day. These formulations should not result in any bleeding, especially if not used soon after the menopause when some irregular break-through bleeding can occur.

Moreover, MHT can be given through different forms and routes:

• Through the skin (transdermal) in the forms of patches, gels and sprays
• Through the mouth (oral) in the forms of tablets

Patches, gels and sprays are preferred to tablet forms in women with gut absorption problems, or who have migraines, abnormal blood pressure, abnormal lipid profiles (e.g. raised triglyceride levels), or are at risk of venous thromboembolic disease (i.e. clotting in the deep veins of the leg or in the lungs) such as in women with obesity or those who smoke. Some medications can interact with MHT when given through the oral route therefore it is always important to review the list of other medications before starting MHT.

For most women, the benefits of taking short-term MHT to improve quality of life for menopause-related symptoms usually outweigh the risks.

In addition to providing relief of menopause-related symptoms, oestrogen also has additional benefits for example to bone health. Consequently, osteoporosis (colloquially referred to as ‘brittle bones’) is more common in women after the menopause. MHT (which contains oestrogen) can therefore offer positive effects on the bone after menopause. Other adjuncts to treatment of women with osteoporosis include vitamin D and calcium supplements, and for some women with a high risk of fracture, additional treatments such as bisphosphonates can be used to improve bone strength. 

Topical treatment for vaginal symptoms – the genitourinary syndrome of menopause (GSM)

Vaginal creams, gel, tablet, pessaries, or a vaginal ring that contain oestrogen, may be helpful for local symptoms such as vaginal dryness or dyspareunia (pain during sex), as well as bladder-related symptoms such as incontinence or urinary tract infections. These local oestrogen preparations do not carry the risks of systemically absorbed MHT (e.g., oestrogen in pills, gels or patches; see below), and can be used safely in all women long-term. They can also be used in addition to systemically absorbed MHT if such symptoms have not been relieved or on their own to provide symptom control locally. As well as vaginal oestrogen, vaginal DHEA is now licensed for vaginal symptoms associated with menopause.

Synthetic versus bioidentical HRT or MHT

‘Progestogen’ refers to any compound with progesterone-like effects, whereas progestins refers to synthetic forms of progesterone. There are synthetic forms of licensed MHT (that are not identical to the natural hormones produced by the ovaries before the menopause) such as Premarin (oestrogens conjugated with sulfate esters), and synthetic types of progesterone e.g. medroxyprogesterone or norethisterone, as well as tibolone (a progestogen with metabolites that have oestrogen-like and androgen-like properties). Older synthetic MHT preparations may be associated with greater risks, for example of blood clots and breast cancer.

There are also MHT preparations containing bioidentical (body-identical) hormones, which are manufactured to be identical to a woman’s natural hormones. There are several licensed ‘body-identical’ MHT preparations available on the NHS. These are safe and regulated, and include oral or transdermal oestradiol preparations, and micronized progesterone. Some of the newer synthetic progestogens, such as dydrogesterone, when combined with synthetic oestrogen appear as safe as the body identical formulations.

However, there are some private, non-NHS providers of menopause care promoting the use of unlicensed and unregulated ‘pharmacy compounded’ MHT preparations (sometime marketed as ‘bioidentical’ or ‘natural’), which means that these preparations are manually put together in the pharmacy. They may sound natural but these unregulated preparations may not contain safe amounts of hormones and so could increase the risks of blood clots and endometrial cancer. There are several licensed preparations that contain oestrogen or progesterone in a form that is identical to that made by the body (and can also be referred to as ‘bioidentical’), however it is important to use only those preparations that have been produced to highest regulatory standards by a licensed pharmaceutical company rather than pharmacy compounded preparations. In short, it is recommended that all women on MHT take only licensed formulations.

Are there any side-effects associated with HRT or MHT?

Side-effects of MHT can include breast-tenderness, water-retention, weight-gain, mood-disturbance, nausea, headaches, and irregular vaginal bleeding. These symptoms can vary by the specific type of MHT used and women should consult their doctor if they have concerns about the side-effects of the MHT that they are taking. Changing the type of MHT preparation or adjusting the dose of hormone treatment can reduce unwanted side-effects.

MHT is primarily indicated to treat women suffering from menopause-related symptoms. There is no time limit on the duration of treatment with MHT, but it is important to consider the balance of risks vs benefits of taking MHT for each individual woman, which should be discussed with a medical professional.

Longer-term use has been linked with a small increase in the risk of breast cancer (discussed in more detail below). The use of oestrogen only HRT in a woman with a uterus increases the risk of endometrial cancer therefore combined HRT (oestrogen and progesterone) is used in this context to avoid this risk. An increased risk of blood clots in the veins (known as venous thrombosis) and of stroke is associated with the tablet form of oestrogen in MHT, but not when MHT is given transdermally (through the skin) such as with patches, gels or sprays.

There are some benefits of MHT including strengthening the bones, which reduces the risk of osteoporosis and broken bones, but this reduction in risk is only during the time of taking MHT. At present there is no evidence to suggest that MHT can prevent dementia.

An updated review of the latest evidence by The National Institute for Health and Care Excellence (NICE), which is the national body responsible for evaluating evidence and making treatment recommendations, is currently ongoing. In general terms, some risks are reduced if MHT is started at younger age (less than 60 years of age), and sooner after the menopause has occurred (within 10 years after menopause).

Additionally, some risks relate to the duration of treatment (see further details on Breast Cancer below) and so it is recommended to have a review with a medical practitioner at 3 months after starting MHT, and then at least once per year thereafter. The current recommendations regarding MHT use is to use the lowest dose for the shortest possible time to control symptoms. MHT can be stopped immediately, or the doses can be gradually reduced. Gradual reduction of the HRT dose may reduce the chances of symptoms reoccurring in the short term but makes no difference in the longer term.

Menopause and Breast cancer

Risks in healthy postmenopausal women

Although the risk of primary breast cancer is low for most women who take MHT, the risk of primary breast cancer diagnosis does increase with all types of MHT over several years. Women with several risk factors for breast cancer should carefully review the balance of risks and benefits with MHT closely over time in discussion with their medical practitioner.

Risk factors for breast cancer include a family history of breast cancer, especially in first degree relatives, excess alcohol intake, sedentary lifestyle, increased bodyweight, smoking, previous radiation exposure to the breast area, dense breasts, and older age.

Risks in women who have had breast cancer

After most types of breast cancer, the risk of recurrence is elevated if a woman takes MHT. There are many safe alternatives to MHT that can be used to help treat menopausal symptoms in women after breast cancer. Lifestyle adjustments can also help. Exercise and staying active can help manage some symptoms of menopause, as well as reducing breast cancer risk, with 30 minutes of walking or other exercise five times per week reported to reduce the risk of breast cancer by up to 55%. If a woman is struggling with symptoms of menopause after breast cancer, her breast cancer team can advise about the best and safest treatment and support.

Non-oestrogen containing treatments

A second-choice alternative to MHT for the treatment of hot flushes, includes non-hormonal medications such as Selective Serotonin Reuptake Inhibitors (SSRI for short), or Serotonin and Norepinephrine Reuptake Inhibitors (SNRI), or clonidine.

A new class of drugs called ‘neurokinin 3 receptor antagonist’ was recently licensed by the MHRA and is now available as a non-oestrogen containing treatment option. Neurokinin 3 receptor antagonists work by blocking the action of a brain chemical called ‘neurokinin B’ or NKB for short, that is responsible for instigating hot flushes. A related class of drugs called ‘neurokinin 1 receptor antagonist’ used in combination with neurokinin 3 receptor antagonist is currently being developed, they could also offer beneficial effects to improve sleep quality. These drugs are very effective for the treatment of hot flushes and have the advantage of not containing oestrogen (nor affecting oestrogen levels), and thus can be used safely in women at increased risk of breast cancer for example (see preceding section on breast cancer risk with MHT for more detail).

There are also non-hormonal lubricants and moisturisers that can help with associated local symptoms such as vaginal dryness. Alternatively vaginal dehydroepiandrosterone (DHEA) called PrasteroneTM is also an option if oestrogen preparations, lubricants and moisturisers are not effective. A selective oestrogen receptor modulator (SERM) tablet called OspemifeneTM can also be tried if topical treatment is not feasible.

Non-pharmaceutical treatments such as cognitive behavioural therapy (CBT) can also help with symptoms such as hot flushes or mood disturbance.

There are also several complementary therapy treatments available, such as St John’s wort, isoflavone, and black cohosh, however it is harder to guarantee the quality of such products, and some can interfere with other medications, so always discuss these with your medical practitioner.

Testosterone treatment

Aside from oestrogen, the ovaries also normally produce other sex hormones such as testosterone in premenopausal women. Therefore, some women can experience symptoms due to low testosterone levels after the menopause, which may include reduced libido (low sexual desire). While low sex drive can be multi-factorial and psychosexual factors should be considered and addressed, a trial of testosterone can also be considered.

This is usually done through a testosterone-containing skin gel or cream. Only one preparation is currently licensed in women (AndrofemeTM) but it is not widely available through the NHS. Some doctors prescribe testosterone gel (which is licensed and widely available for use in men), for use in postmenopausal women at a lower dose. The main concern is excess testosterone replacement, which can cause side-effects such as acne, increased facial and body hair, mood and voice changes. So, testosterone replacement for menopause-related symptoms should only be prescribed by a doctor experienced in prescribing this in women.