Menopause Assessment and HRT

Overview

Menopause Assessment and Hormone Replacement Therapy (HRT) is the specialist evaluation and individualised treatment of women experiencing the menopausal transition — the permanent cessation of menstruation caused by progressive ovarian follicle depletion. In the UK, menopause occurs at an average age of 51 years and the perimenopause — the transitional phase with fluctuating ovarian function — may begin several years earlier with a significant symptom burden. HRT is the most effective treatment available for menopausal vasomotor symptoms and provides additional long-term health benefits including osteoporosis prevention and cardiovascular protection when initiated within 10 years of the final menstrual period. Modern body-identical transdermal HRT formulations have a substantially more favourable safety and risk profile than older oral synthetic preparations.

Types of Menopause Assessment and HRT

• Systemic transdermal HRT — oestradiol delivered via patch, gel, or nasal spray combined with micronised progesterone for women with an intact uterus
• Oestrogen-only HRT — transdermal oestradiol prescribed for women who have had a hysterectomy; does not increase breast cancer risk
• Sequential (cyclical) HRT — oestrogen continuously with progesterone added for 12 to 14 days per month producing a regular monthly bleed in perimenopausal women
• Continuous combined HRT — oestrogen and progesterone both taken daily producing amenorrhoea suitable for women more than 12 months post-menopause
• Topical vaginal oestrogen — low-dose local oestrogen cream, pessary, or ring for genitourinary syndrome of menopause (GSM) used separately and indefinitely

Risk Factors of Menopause Assessment and HRT

• Premature ovarian insufficiency (POI) below the age of 40 associated with significantly increased long-term cardiovascular and skeletal health risks
• Surgical menopause following bilateral oophorectomy causing an abrupt and frequently more severe menopausal syndrome than natural menopause
• Personal history of breast cancer requiring careful individualised risk-benefit assessment and often specialist oncology input before considering HRT
• Personal or family history of venous thromboembolism influencing the choice of HRT route — transdermal oestradiol does not increase VTE risk unlike oral oestrogen
• Obesity (BMI above 30) associated with greater endogenous peripheral oestrogen production but also increased breast cancer and cardiovascular risk
• Early menopause (age 40 to 45) associated with substantially increased risk of cardiovascular disease and osteoporosis if HRT is not initiated

Symptoms of Menopause Assessment and HRT

• Hot flushes — sudden intense episodes of heat spreading from the chest to the neck and face lasting 2 to 4 minutes occurring multiple times daily
• Night sweats — drenching nocturnal perspiration causing significant sleep disruption and profound daytime fatigue
• Sleep disturbance — persistent difficulty initiating or maintaining sleep causing cognitive impairment, irritability, and reduced quality of life
• Mood changes — anxiety, irritability, low mood, and tearfulness without a previous psychiatric history occurring in the perimenopause
• Brain fog — difficulty concentrating, short-term memory impairment, word-finding difficulty, and reduced mental clarity
• Vaginal dryness, itching, and dyspareunia from progressive urogenital atrophy in genitourinary syndrome of menopause
• Urinary urgency, frequency, and recurrent urinary tract infections from oestrogen-deficient urethral and bladder mucosal atrophy
• Joint and muscle aches, reduced bone density, and increased fracture risk from oestrogen-deficient skeletal effects