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Appendix 1 – Counselling

View HRT Guidance Flow Chart


Symptoms Associated With The Menopausal Transition

These include:

  • Hot flushes
  • Night sweats
  • Vaginal Dryness
  • Menstrual irregularity

Symptoms not specific to menopause include:

  • Lack of concentration
  • Failing memory
  • Sexual dysfunction
  • Arthralgia
  • Depressed mood

N.B. Exclude cyclical symptoms and PMS


Consider breast, abdominal and pelvic examinations if clinically indicated



  • Lifestyle
  • Medication
  • Alternative therapies


  • Types available
  • Indications for use
  • Patient preference

Advice and Information

Physiology including:

  • Average age of the menopause in the U.K. is 50.7 years
  • 5% of women undergo the menopause at age < 45 years
  • 1% undergo the menopause at age < 40 years
  • Irregular cycle common in the perimenopause
  • Intermenstrual bleeding requires endometrial assessment

Benefits of HRT

  • Symptom relief and urogenital atrophy
  • Prevention of osteroporotic fractures
  • Reduces risk of heart disease
  • Delays onset of Alzheimer’s Disease
  • Reduces risk of colon cancer
  • Reduction of late onset diabetes

Risks of HRT

Each of these factors will vary in importance for each woman and will need assessing individually

No Contraindication to HRT or Positively Indicated

Asthma HRT not contraindicated if stable. If poorly controlled, stabilise before initiating HRT. Estrogen may improve and progestogens may exacerbate the symptoms.
Benign Breast Disease  Proven benign breast disease is not a contraindication.
CIN, Abnormal Smears and Carcinoma or Cervix Not contraindicated.
Contact Lens Wearers May alter corneal curvature. Rarely a problem in practice.
Depression Estrogen not contraindicated. Progestogens may exacerbate problems.
Diabetes HRT – no evidence of diminished glycaemic control. Advise referral to specialist menopause clinic.
Endometriosis If asymptomatic, may prescribe HRT. Rarely causes activation of disease. Consider use of continuous combined therapy to suppress endometriotic foci even after hysterectomy.
Hyperlipidaemia HRT has a beneficial effect on lipid profile. May be used in conjunction with diet and other lipid lowering agents. Oral estradiol increases triglycerides and transdermal preparations decrease triglycerides.
Hypertension Oral HRT rarely causes increase in BP and may cause a small fall in BP secondary to vasodilation. Regimens with drospirenome reduce BP. Long term studies tend to show a drop of about 2mm Hg with HRT. Monitor in a routine manner.

For follow-up, visit Appendix 11

For ongoing support, visit Appendix 13