Menopause and hormone replacement therapy

• Menopause is the permanent end of menstruation from loss of ovarian follicular function and the fall in circulating oestrogen; natural menopause usually occurs between 45 and 55 years of age, and is confirmed after 12 months without periods. ^{[1][2] [5]}
• Vasomotor symptoms (hot flushes and night sweats) affect 50 to 82% of women who go through natural menopause, and symptoms often start in perimenopause, sometimes years before the final period. ^[2]
• Menopausal hormone therapy (HRT) is the most effective treatment for vasomotor and genitourinary symptoms and also prevents bone loss, with the best balance of benefit and risk for women younger than 60 years or within 10 years of menopause onset who have no contraindications. ^[2][5][6]
• HRT should be tailored to the woman: combined (oestrogen plus progestogen) if she has a uterus, oestrogen-only after a total hysterectomy, with transdermal oestrogen preferred when venous thromboembolism risk or BMI is raised. ^[1]
• Premature ovarian insufficiency (before age 40) usually has no clear cause and is managed by replacing hormones, with HRT (or a combined contraceptive) recommended until at least the average age of natural menopause (about 51 years), unless contraindicated. ^[1][4][5]

By the end of this page you should be able to:

1. Define menopause, perimenopause and premature ovarian insufficiency, and describe how each is diagnosed without over-testing.
2. Explain the hormonal changes of menopause and how they produce vasomotor, urogenital, mood and skeletal effects. ^[2]
3. Describe the differential diagnosis of oligomenorrhoea and amenorrhoea around the menopause, and know which tests are useful and which are not.
4. Apply a stepwise approach to assessment, investigation and treatment, including route, regimen and dose principles of HRT.
5. List the absolute and relative contraindications to HRT and the women in whom HRT is especially beneficial.
6. Counsel a woman on benefits, risks and alternatives, including non-hormonal treatments, long-term health and contraception, using the current guidance.

Menopause is not a disease. It is a normal life transition that marks the end of reproductive years and the beginning of a long post-reproductive phase. ^[2] The definition matters because it determines when a woman is "postmenopausal" for clinical decisions, including contraception and HRT dosing.

Perimenopause is the transitional period from when the menstrual cycle starts changing until 12 months after the final menstrual period. ^[5] Hormone levels fluctuate rather than simply fall, so cycles become irregular, shorter or longer, and bleeding can be heavier or lighter before stopping altogether. ^[5] Many women develop vasomotor and other symptoms during this phase, sometimes several years before the final bleed. ^[5]

These terms are often used loosely; the useful distinction is by age. ^[5]

• Early menopause: menopause between 40 and 44 years of age. ^[5]
• Premature menopause / premature ovarian insufficiency (POI): loss of ovarian activity before 40 years of age. The preferred modern term is premature ovarian insufficiency. ^[5][6]
• Primary ovarian insufficiency is sometimes used interchangeably with POI in US literature. ^[3]

POI is important clinically because its consequences (infertility, bone loss, cardiovascular risk) are serious and because it is often under-recognised. ^[1][5]

Menopause can be induced by surgery (bilateral oophorectomy, and sometimes hysterectomy with ovarian removal), pelvic radiotherapy or chemotherapy. ^[2][5] Women with this form of menopause often have abrupt, severe symptoms because the hormonal fall is sudden rather than gradual. ^{[2] [1]}

For consistency, many guidelines use the STRAW+10 staging system, which divides reproductive life into stages from early reproductive age through to late postmenopause, using bleeding patterns and FSH levels. ^[5] You do not need to memorise the stages, but they explain why hormonal tests are unreliable in perimenopause: hormone levels swing, and only a sustained elevation is meaningful. ^[1][5]

Natural menopause occurs between 45 and 55 years of age for women worldwide; the average age in countries such as the UK and Australia is about 51 years. ^[2][4][5] The pace and age are broadly consistent across populations, but some women experience menopause earlier. ^[2]

• Prevalence of symptoms. About 75% of women experience symptoms during perimenopause and after menopause, and about 25% experience moderate to severe symptoms that affect quality of life. ^[5] Vasomotor symptoms (hot flushes and night sweats) are the most commonly reported menopausal symptom, with a reported prevalence of 50 to 82% among women who experience natural menopause. ^{[3] [2]}
• Premature/early menopause. Premature ovarian insufficiency (before 40) and early menopause (40-44) are much less common than natural menopause. Causes include chromosomal abnormalities (such as Turner syndrome), autoimmune disease, surgery, chemotherapy or radiotherapy, and unknown (idiopathic) causes. ^[2][6]
• Population. The global population of postmenopausal women is growing: in 2021 women aged 50 years and over accounted for 26% of all women and girls worldwide, up from 22% a decade earlier; a woman aged 60 in 2019 could expect to live on average another 21 years. ^[2]
• Predicting individual timing is not possible, although associations exist with age at first period, parity, body weight, smoking, some medical treatments and genetics. ^[2]

The only confirmed cause of natural menopause is biological ageing of the ovarian follicle pool. ^[2] By menopause, the ovaries contain too few follicles to respond to normal gonadotrophin drive. ^[2]

Risk factors for earlier menopause (that is, before 40) include:

• Genetic/chromosomal causes (e.g. Turner syndrome, Fragile X premutation) and family history. ^[2][6]
• Autoimmune disease, which can also be associated with other endocrine deficiencies. ^[2]
• Iatrogenic causes: bilateral oophorectomy, hysterectomy (often advances timing), chemotherapy or pelvic radiotherapy. ^[2][5]
• Lifestyle factors such as smoking are commonly reported as associated with earlier menopause in reviews, although the quality and size of these associations vary between studies; weight, parity and age at menarche also show associations. ^[2]

There is no known modifiable risk factor that can prevent the timing of natural menopause. ^[2]

The core change is a fall in the number and function of ovarian follicles, which reduces production of oestradiol (the main circulating oestrogen before menopause) and inhibin. ^[2] With less negative feedback on the pituitary, follicle-stimulating hormone (FSH) rises and luteinising hormone (LH) rises. ^[2] Progesterone falls because ovulation becomes infrequent and then stops.

The clinical effects follow from the loss of oestrogen in target tissues:

• Vasomotor. Oestrogen helps stabilise the thermoregulatory centre in the hypothalamus. Its fall narrows the thermoneutral zone, so small changes in core temperature trigger disproportionate heat-loss responses: dilatation of skin vessels (flush), sweating and a sensation of heat. ^[5]
• Genitourinary. Oestrogen maintains vaginal epithelial thickness, lubrication, blood flow and urinary tract mucosa. Loss produces thinning (atrophy), dryness, dyspareunia, urgency, frequency and recurrent infections. ^[3][5]
• Bone. Oestrogen restrains osteoclast activity. Its fall accelerates bone resorption, particularly in trabecular bone, leading to loss of bone mineral density and increased fracture risk. ^[2]
• Cardiovascular. Oestrogen has favourable effects on the lipid profile, endothelial function and vascular tone. After menopause women lose their relative cardiovascular advantage over men, and cardiovascular risk rises with age. ^[2]
• Brain. Oestrogen modulates neurotransmitters involved in mood, sleep and temperature. Many women report poor sleep, "brain fog" and mood change around the menopause. ^[5]
• Musculoskeletal and skin. Joint aches, muscle stiffness, and changes in skin and hair are commonly reported. ^[2][5]

In perimenopause the picture is one of fluctuation: oestradiol swings between high and low, FSH may be normal or high on a given day, and symptoms often precede the final bleed. ^[5] This is why a single blood sample in a symptomatic 47-year-old is unhelpful.

Symptoms vary enormously; some women have few or none, others have severe and disabling symptoms lasting years. ^[2] A good history asks about all of them and how they affect daily life.

Vasomotor symptoms

• Hot flushes: a sudden feeling of heat in the face, neck and chest, often with skin flushing, sweating, palpitations and physical discomfort, lasting minutes. ^[2]
• Night sweats, often with sleep disruption.
• Symptoms may continue for several years in some women. ^[5]

Menstrual changes

• Cycles become shorter or longer, flow heavier or lighter, and eventually cease. ^[5]
• Bleeding after 12 months of amenorrhoea (postmenopausal bleeding) is not explained by menopause and must be investigated for endometrial disease.

Genitourinary syndrome of menopause

• Vaginal dryness, burning and itching.
• Pain during intercourse (dyspareunia), urinary urgency, frequency, nocturia.
• Recurrent urinary tract infections.
• ^{[3] [5]}

Mood, sleep and cognition

• Depressed mood, anxiety, irritability.
• Insomnia, especially with night sweats.
• "Brain fog", concentration and memory difficulties.
• ^[5]

Musculoskeletal

• Joint and muscle aches.
• Low sexual desire can be a standalone complaint; note also local genital discomfort. ^[1]

Other changes worth asking about

• Body composition (weight gain, change in fat distribution) and cardiovascular risk. ^[2]
• Pelvic floor symptoms: menopause weakens pelvic support and can increase the risk of prolapse. ^[2]

Examination is often normal and is mainly aimed at excluding other causes of irregular bleeding and amenorrhoea, and at documenting comorbidity for HRT safety. ^[5][6]

• General: blood pressure; BMI/weight; signs of thyroid disease; skin changes (e.g. vitiligo, suggesting autoimmune association). ^[5]
• Gynaecological: inspect vulval and vaginal epithelium (pale, thin, dry epithelium suggests atrophy); assess pelvic floor and prolapse; perform cervical screening as indicated. ^[3][5]
• Breasts: clinical breast examination as appropriate for age and risk; arrange mammography as per national screening. ^[5]
• Cardiovascular and bone: look for hypertension, and consider fracture risk assessment in women over 50 or with other risk factors. ^[1][5]

Around the menopause the differential diagnosis has two parts: other causes of irregular bleeding or amenorrhoea, and other causes of the symptoms.

NICE is explicit: in an otherwise healthy woman aged 45 or over with menopause-associated symptoms, diagnose on history alone. ^[1] Do not use anti-Müllerian hormone (AMH), inhibin A, inhibin B, oestradiol, antral follicle count or ovarian volume to identify menopause in women 45 or over. ^[1] Do not use FSH in women taking combined oestrogen and progestogen contraception or high-dose progestogen. ^[1]

• Bone health: for women over 65, or with other fracture risk factors, use a fracture risk tool (e.g. FRAX) and consider DEXA as indicated; recommend weight-bearing exercise, calcium and vitamin D intake, and smoking/alcohol advice. ^[5]
• Cardiovascular risk: lipid profile, blood pressure and diabetes risk assessment; advise lifestyle measures. ^[5][6]
• Pelvic ultrasound if bleeding is atypical, heavy, or postmenopausal, to exclude structural disease. ^[5]
• Breast screening: follow the national programme; clinically evaluate any new breast symptom. ^[5]

Perimenopause is the phase of fluctuating ovarian function. FSH can be normal, high or very high on any given day, so a single normal result never excludes perimenopause. ^[1][5] Testing becomes useful when menopause is suspected under 40, or when an atypical presentation needs clarification. ^[1]

Good menopause care is individualised. ^[1][6] Every treatment decision weighs symptoms, age, time since menopause, personal and family medical history, preferences, and the evidence. ^[1][6]

Key principles:

• HRT is the most effective treatment for vasomotor symptoms (hot flushes and night sweats) and for genitourinary symptoms, and prevents bone loss and fracture. ^[1][6]
• For women under 60 or within 10 years of menopause onset with no contraindications, the benefit-risk ratio is favourable. ^[6]
• HRT should not be used solely for the primary prevention of cardiovascular disease in women aged 45-55 experiencing menopause. ^[1]
• Treat the woman, not the laboratory result. Most women over 45 do not need blood tests before starting HRT. ^[1]
• Individualise dose and route, starting low and titrating to symptom control, and review regularly. ^[1][5]
• Offer all options: lifestyle change, HRT, menopause-specific CBT, and non-hormonal drugs. ^[1][5]

Route: systemic oestrogen is started at a low to moderate dose and adjusted to symptoms; transdermal (patch, gel, spray) avoids first-pass hepatic metabolism and is preferred when venous thromboembolism (VTE), liver, migraine-with-aura or cardiovascular risk factors exist. ^[4][5] Oral oestrogen should be avoided in women at high VTE risk. ^[5]

Progestogen choice: micronised progesterone and dydrogesterone are structurally closer to natural progesterone and observational data suggest they may carry a lower breast cancer risk than older synthetic progestogens; they are considered first-line for most women. ^[5] NICE advises seeking advice from a clinician with specialist knowledge of the condition when a woman has a condition that may be affected by HRT. ^{[1] [4]}

Dosage: aim for the lowest effective dose, titrate; review at 3 months and annually thereafter. ^[1][5]

• Offer HRT for vasomotor symptoms associated with menopause. ^[1]
• Consider HRT for depressive symptoms without full diagnostic criteria that begin around the menopause, alongside other management. ^[1]
• For genitourinary symptoms, offer vaginal oestrogen (see below), plus non-hormonal moisturisers/lubricants. ^[1]
• Consider testosterone supplementation for low sexual desire if HRT alone is not effective (off-label use in many countries; counsel accordingly). ^[1][4]
• For premature ovarian insufficiency, see special groups: HRT (or combined contraceptive) recommended until at least age 51 unless contraindicated. ^[1]

Benefits reported consistently across guidelines:

• Most effective treatment for vasomotor symptoms and genitourinary symptoms. ^[1][6]
• Prevents bone loss and fracture while on treatment (benefit declines after stopping). ^[1][6]
• RCOG patient materials and reviews report HRT can reduce the risk of heart disease if started under 60. ^[4]
• Combined (oestrogen plus progestogen) HRT does not increase coronary heart disease risk. ^[1]

ACOG's patient materials similarly advise that systemic hormone therapy is usually not recommended in women who have ever had breast or endometrial cancer, stroke, heart attack, blood clots or liver disease. ^[3] NICE adds that people with coronary heart disease or stroke should have combined or oestrogen-only HRT discussed with and offered, if appropriate, by a clinician with expertise in menopause. ^[1]

• Review after 3 months to assess efficacy and tolerability, then annually (or sooner if ineffective/side effects). ^[1][4][5]
• Unscheduled bleeding within the first 3-6 months on systemic HRT is common; bleeding after 3 months (NICE) or beyond 6 months (RCOG) should be investigated. ^[1][4]
• Reassess need for continued therapy periodically; there is no arbitrary limit on duration, and HRT can be continued if symptoms persist, with annual benefit-risk review. ^[4][5] Women may stop suddenly or gradually. ^[1]
• Stop systemic HRT if breast cancer is diagnosed. ^[1]
• Keep up with national cancer screening, blood pressure, lipids and bone health assessments. ^[1][4]

Oral oestrogen undergoes first-pass hepatic metabolism and increases coagulation factors, producing a 2- to 3-fold increase in VTE, although the absolute risk remains low. ^[5] Transdermal oestrogen does not carry this increase and is the route of choice for women with VTE risk factors, BMI over 30, or a personal/family history of thrombosis. ^[1][5]

• Breast. Combined (oestrogen plus progestogen) HRT is associated with an increased incidence of breast cancer with longer duration; the risk falls after stopping. Oestrogen-only HRT is associated with little or no increase, and possibly a reduction, in breast cancer risk. ^[4] Observation data suggest micronised progesterone/dydrogesterone may confer lower risk than older synthetic progestogens, but evidence is not definitive. ^[5]
• Endometrium. Unopposed oestrogen causes endometrial hyperplasia; adequate progestogen protects. Continuous combined HRT lowers endometrial cancer risk relative to non-use; sequential (cyclic) may slightly increase risk, more with longer duration, fewer progestogen days and higher oestrogen dose. ^[1]
• Ovary. A slight increase in ovarian cancer risk is seen; baseline risk under 60 is very low. ^[1]

• Offer low-dose vaginal oestrogen to women with genitourinary symptoms, with or without systemic HRT; absorption is largely local, with minimal systemic effect. ^[1][3]
• Advise that symptoms often return when vaginal oestrogen is stopped, but it can be restarted. ^[1]
• If vaginal oestrogen is unsuitable or not tolerated (or ineffective), consider vaginal prasterone or (if local treatments impractical, e.g. disability) oral ospemifene. ^[1]
• Non-hormonal moisturisers/lubricants are first for women with a personal history of breast cancer; vaginal oestrogen may be considered if symptoms persist after non-hormonal measures, collaborating with a breast cancer specialist when on aromatase inhibitors. ^[1]
• Vaginal laser therapy should not be offered unless within a randomised trial. ^[1]

Non-drug measures supported by guidelines and reviews:

• Menopause-specific CBT is effective for vasomotor symptoms, sleep difficulties (e.g. night-time awakening) and depressive symptoms, and can be used alone (when HRT contraindicated or not wanted) or alongside HRT. ^[1][5]
• Fezolinetant, a neurokinin-3 receptor antagonist, is recommended by NICE as an option for moderate to severe vasomotor symptoms when HRT is unsuitable. ^[1]
• Isoflavones or black cohosh have some evidence for vasomotor relief, but preparation quality and safety vary; bio-identical compounded hormones are not recommended because of unproven dosing/safety. ^[1][5]
• Lifestyle: weight loss, limiting alcohol/caffeine, smoking cessation, exercise and temperature control of the bedroom. ^[4][5]
• St John's wort may help vasomotor symptoms, but has serious interactions (tamoxifen, anticoagulants, anticonvulsants) and uncertain dosing. ^[1]
• SSRIs, SNRIs and clonidine should not be routinely offered as first-line for vasomotor symptoms alone. ^[1]

NICE recommends diagnosis on symptoms plus raised FSH on two samples 4-6 weeks apart, not a single test, and recommends referral if doubt. ^[1] Causes include chromosomal abnormalities, autoimmune disease, surgery, chemotherapy or radiotherapy, and idiopathic; a thorough history (including family, fertility plans) is essential. ^[2][6]

Management:

• Offer sex steroid replacement: either HRT or a combined hormonal contraceptive, unless contraindicated (e.g. hormone-sensitive cancer). ^[1]
• Replacement should continue until at least the average age of natural menopause (about 51) to protect bone and cardiovascular health and control symptoms. ^[1][4][5]
• HRT may have a beneficial effect on blood pressure compared with a combined oral contraceptive; both provide bone protection; HRT is not contraceptive (use contraception separately if needed). ^[1]
• Background risks of breast cancer and heart disease climb with age but are minimal before 40; replacing missing hormones in POI does not add excess long-term risk for most women. ^[1][6]
• Offer psychological support, fertility counselling and referral to reproductive medicine/endocrinology. ^[1][6]
• Early menopause (40-44): offer psychological support if distressed. ^[1]

Refer to a clinician with expertise in menopause when:

• symptoms persist despite optimal therapy; ^[1]
• contraindications to HRT or uncertainty about the best option; ^[1]
• POI, symptoms after cancer treatment (e.g. adjuvant aromatase inhibitors), or complex comorbidity (coronary disease, stroke, VTE, clotting disorder, severe migraine with aura); ^[1][5]
• troublesome unscheduled bleeding on HRT; ^[1]
• the woman requests a second opinion or has concerns about treatment. ^[1]

• Osteoporosis and fracture: accelerated postmenopausal bone loss; HRT prevents loss while used, benefit declines after stopping. ^[1][2]
• Cardiovascular disease: loss of the pre-menopausal advantage; uncontrolled risk factors matter more than menopause itself; HRT is not primary prevention. ^[2][1]
• VTE: oral HRT increases risk; absolute risk low but higher with age, obesity, thrombophilia or immobility. ^{[5] [1]}
• Stroke: slightly increased with oral oestrogen; very low absolute risk under 60; transdermal does not carry this increase. ^{[1][5] [4]}
• Breast cancer: combined HRT increases risk with duration; oestrogen-only does not; tibolone is contraindicated after breast cancer. ^[4][5]
• Endometrial hyperplasia/cancer: if oestrogen is given without adequate progestogen to a woman with a uterus. ^[4][5]
• Genitourinary atrophy: urinary symptoms, recurrent infections and prolapse. ^[2][3]
• Mood/sleep sequelae: persistent insomnia, low mood; consider depression properly. ^[1]
• Fertility loss and its psychosocial impact, particularly in POI. ^[6]

Most menopausal symptoms are self-limiting over several years, but their duration is unpredictable. ^[5] About 25% of women have moderate to severe symptoms that significantly affect quality of life; some experience vasomotor symptoms for a decade. ^[5] Long-term health (bone, cardiovascular) depends far more on age, comorbidity and lifestyle than on whether HRT was used for symptom control. ^[1] Overall life expectancy is unlikely to be changed by HRT within licensed doses. ^[1] Women generally require follow-up for as long as symptoms or HRT continue, and even after stopping, a review of cardiovascular, bone and cancer risk remains valuable. ^[4][5]

• Bone: advise weight-bearing exercise (e.g. walking, stair-climbing), adequate calcium and vitamin D, smoking cessation and limiting alcohol; consider HRT for symptom control (with bone benefit) in appropriate women; bisphosphonates/alendronate etc. only if osteoporosis is documented. ^{[2][4][5] [1]}
• Cardiovascular: smoking cessation, weight management, exercise, blood pressure and lipid control; treat risk factors per national guidance. HRT is not primary prevention of CVD. ^[1][5]
• Cancer screening: keep up with breast, cervical and bowel screening programmes; evaluate unexplained postmenopausal bleeding promptly. ^[1][4]
• Contraception: pregnancy is still possible during perimenopause; advise contraception (such as barrier or hormonal methods) until 12 consecutive months without periods. ^[2][4]
• Sexual health: STI/HIV risk persists after menopause; vaginal thinning increases transmission risk during intercourse; practise safer sex. ^[2]
• General wellbeing: stress management, sleep hygiene, pelvic floor exercises and sexual counselling; assess mood. ^[4][5]

Menopause is a diagnosis of the end of fertility, and pregnancy after natural menopause is unlikely without donor eggs or previously frozen embryos. ^[2] During perimenopause, however, ovulation can still occur and pregnancy is possible, so contraception should continue until 12 consecutive months without menstruation. ^[2] HRT and other hormones are not for use in pregnancy; stop if pregnancy is suspected. ^[3]

POI in a young person is uncommon and often signals a genetic or autoimmune condition; offer genetic and endocrine assessment and support. ^[2][6] Replacement oestrogen at physiological doses supports pubertal development, bone accrual, uterine growth and cardiovascular health; a progestogen is added in cycles once breakthrough bleeding occurs. ^[6] Children of an affected mother have a 50% chance of inheriting an autosomal dominant condition such as Turner/Fragile X, where applicable. ^[6] Fertility discussion and referral should be offered. ^[1][6]

There is no maximal duration of HRT. ^[5] Women aged 65 or over who remain symptomatic may, after counselling and annual reassessment, continue treatment, often at lower doses and preferably via transdermal oestrogen, since VTE/stroke risk rises with age and comorbidity. ^[5][6] Women over 65 newly starting systemic HRT require more cautious, individualised assessment. ^[5] Stopping purely because of age is not supported by evidence, but each year's benefit-risk review is essential. ^{[4][6] [1]}

Systemic HRT is generally avoided in women with a history of hormone-sensitive cancer. ^[5] For genitourinary symptoms after breast cancer, offer non-hormonal moisturisers/lubricants first, and consider vaginal oestrogen (off-label) after specialist discussion; avoid fluoxetine and paroxetine with tamoxifen. ^[1] Refer to a clinician with expertise in menopause and collaborate with the oncology team. ^[1][5]

• Menopause is the final menstrual period or permanent cessation of ovarian function, diagnosed clinically after 12 months of amenorrhoea; perimenopause is the transition including menstrual change and can last years. ^{[2][5] [4]}
• Natural menopause usually occurs between 45 and 55 years (average about 51). Hot flushes and night sweats affect 50 to 82% of women. ^[2][3]
• HRT is the most effective treatment for vasomotor and genitourinary symptoms and prevents bone loss; it has the best benefit-risk balance for women younger than 60 or within 10 years of menopause without contraindications. ^[1][6]
• Offer combined HRT when a uterus is present and oestrogen-only after hysterectomy; use transdermal oestrogen when VTE risk is raised or BMI is 30 or above. ^[1][5]
• Contraindications include hormone-dependent cancers, undiagnosed bleeding, acute VTE or cardiovascular event, severe liver disease and porphyria; caution with migraine with aura, hypertriglyceridaemia and liver disease. ^[5]
• HRT is not contraception; it does not increase or decrease overall life expectancy within licensed doses; oral HRT raises VTE and stroke risk (small, absolute), transdermal does not. ^[1][5]
• POI (<40 years) is diagnosed on symptoms plus two raised FSH levels 4-6 weeks apart, and should be treated with HRT or a combined contraceptive until about age 51. ^[1][4]
• Genitourinary symptoms are best treated with low-dose vaginal oestrogen (plus moisturisers/lubricants); consider prasterone or ospemifene when these fail. ^[1]
• Menopause-specific CBT, fezolinetant, gabapentin and (with caution) clonidine are useful non-hormonal options; SSRIs/SNRIs and clonidine are not first-line for vasomotor symptoms alone. ^[1][5]
• Review HRT at 3 months and annually; there is no fixed maximum duration if symptoms persist and benefits outweigh risks. ^[1][5]

Related topics include osteoporosis and fracture risk, cardiovascular risk assessment, polycystic ovary syndrome, premature ovarian insufficiency, depression and anxiety disorders, urinary incontinence and pelvic organ prolapse, breast cancer risk assessment and tamoxifen interactions, contraception for women over 40, and bone health and calcium/vitamin D.