NICE’s existing guidance said investigations and examinations are not routinely indicated before starting hormone replacement therapy unless there is a:1

·       sudden change in the menstrual pattern or unexplained bleeding;

·       personal or family risk of venous thromboembolism;

·       high risk of breast cancer;

·       risk of arterial disease;

·       history of gynaecological disease.

NICE recommendations on HRT for vasomotor symptoms and for mood changes consider whether the woman had a uterus or not, eg due to hysterectomy:1

·       with a uterus, an oral or transdermal combined (oestradiol plus progestogen) HRT preparation may be offered

·       without a uterus, offer an oral or transdermal oestrogen-only preparation;

·       for women diagnosed with POI, offer a sex steroid replacement with a choice of HRT or a combined oral contraceptive unless contraindicated, eg in women with hormone-sensitive cancer.

Women with urogenital atrophy may benefit from low-dose vaginal oestrogen. Off-label use of testosterone supplementation may be suitable for sexual dysfunction.

Management regimes should be reviewed after three months and then annually. If HRT is started during perimenopause, then consider whether the treatment regimen should be modified or doses reduced.

HRT may be needed for 2-5 years for vasomotor symptoms, but vaginal oestrogen may be required for much longer as symptoms may return once stopped.