CKS Clinical solutions - Perimenopause

THE CASE: A 47-year-old woman (with an intact uterus) consults complaining of hot flushes and night sweats. She would like treatment, but is concerned about the risks of HRT. How should I assess?

Advise sleep hygiene
Advise sleep hygiene

Assess her risk of cardiovascular disease (CVD) and osteoporosis, check BMI and BP, and determine if she has any contraindications to HRT, including:

  • Hormone-dependent cancer;
  • Angina or recent MI;
  • DVT, PE or current pregnancy;
  • Severe active liver disease;
  • Undiagnosed breast mass;
  • Uninvestigated abnormal vaginal bleeding.

Investigations or referral should be considered if she has abnormal vaginal bleeding or a sudden change in menstrual pattern, a history of DVT or PE, a high risk of breast cancer, CVD or multiple risk factors for CVD.

What advice should I give?
Explain that systemic HRT is effective for treating menopausal symptoms. Systemic, combined HRT increases the risks of breast cancer, ovarian cancer and VTE.

From 50 to 59 years of age, combined HRT increases the risk of breast cancer from 10 to 16 cases per 1,000 HRT users after five years of use, and from 20 to 44 cases per 1,000 HRT users after 10 years of use. However, risk decreases to normal within five years of stopping. The risk of VTE may be lower with transdermal estrogen.

Most women require two to three years of treatment, but some women may need longer. Regular attempts to stop topical treatment are recommended, but topical (vaginal) estrogen may be required long term.

Are there any alternatives to HRT?
For vasomotor symptoms, consider a trial of clonidine for two weeks. A two-week trial of paroxetine, fluoxetine, citalopram or venlafaxine could be considered. For vaginal dryness, a vaginal lubricant may be helpful.

How should she be managed?
Offer systemic (oral or transdermal), cyclical combined HRT for vasomotor symptoms. Review three months after starting HRT and annually thereafter.

Consider switching from cyclical to continuous combined HRT when she is older than 54 years or, if she has experienced six months of amenorrhoea (or had increased FSH levels) in her mid-40s, after taking cyclical HRT for several years.

CKS have based these recommendations on an RCOG guideline,1 a British Menopause Society consensus statement,2 and other guidelines, consensus statements and published expert opinion (see the CKS website).

Evidence on the benefits and risks of HRT is also derived from a systematic review3 and a large randomised controlled trial.4,5

Recommendations on alternatives to HRT are based on evidence from a systematic review.6 Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP. See


1. Hormone replacement therapy and venous thromboembolism. Guideline 19, RCOG, 2004.

2. Managing the menopause. British Menopause Society Council consensus statement on hormone replacement therapy, 2006.

3. MacLennan A H, Broadbent J L, Lester S, Moore V. Cochrane Database Syst Rev 2004 Oct 18; (4): CD002978.

4. Rossouw J E, Anderson G L, Prentice RL et al. JAMA 2002; 288(3): 321-33.

5. Barnabei V M, Cochrane B B, Aragaki A K et al. Obstet Gynecol 2005; 105(5 Pt 1), 1,063-73.

6. Nelson H D, Vesco K K, Haney E et al. JAMA 2006; 295(17): 2,057-71.

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