Types of treatment

1. IMS Updated Recommendations on postmenopausal hormone therapy. Climacteric 2007:10;181-194
2. British Menopause Society Council Consensus Statement. Alternative and Complementary Therapies. 5 June 2007. http://www.thebms.org.uk/statementcontent.php?id=2
3. Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update. Vol 1 Issue 2 September 2007
4. Rossouw JE et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA 2007; 297:1465-77

Vaginal therapy includes vaginal tablets, creams, rings and suppositories which are inserted into the vagina to help relieve the vaginal symptoms of the menopause. These deliver oestrogen directly to the tissues of the vagina.They are easy to use and easy to stop. They are sometimes referred to as 'local therapy'.

For women who have only vaginal symptoms, it may be worth trying one of these local preparations.

If menopausal symptoms are more general, a form of treatment which circulates throughout the whole body (known as "systemic treatment" which is most commonly applied by tablets taken by mouth, or skin patches) may be more appropriate.

Sequential combined hormone replacement therapy imitates the natural cycle of a woman. While oestrogen is taken on every day of the 28-day treatment, progestogen is only added during the second half, for 10-14 days.

After the final tablet containing progestogen, a menstruation-like bleed occurs.

Oestrogen and progestogen are taken together daily throughout the 28-day cycle leading to complete cessation of menstrual bleeding while relieving menopausal symptoms.

The most common and most convenient is a fixed combination of oestrogen and progestogen in a single tablet.

Although occasional spotting (loss of small amounts of blood) may occur, bleeding stops completely in the majority of women after a few months of therapy and a completely bleed-free condition may be achieved.

This is similar to monthly sequential therapy but while estrogen is given constantly, progestogen is added only every 3 months, instead of every month.

A menstruation-like bleed therefore occurs only four times a year and lasts an average of 5–6 days.

The likelihood that intermediate bleeding (called ‘breakthrough bleeding’) will occur is higher with long-cycle than with sequential therapy.

Long-cycle therapy has been shown not to protect the endometrium as effectively as conventional sequential combined therapy.

In women who have had their womb removed (hysterectomy), there is no longer any risk that the growth of the inner lining of the womb could be over stimulated by oestrogen. Therefore, it is usually not necessary to add a progestogen, and oestrogen-only therapy can be taken.

Oestrogen only HRT is given continuously at the lowest possible dose for symptom relief.

Vaginal treatment usually is also oestrogen only treatment. These preparations only contain low doses of oestrogen and the main effect is locally in the vagina. Thus, there is no overstimulation of the growth of the inner lining of the womb and it is not necessary to add a progestogen even if a woman still has her womb.

Some women use medicinal herbs or other supplements such as isoflavones (phytoestrogens), evening primrose, black cohosh and ginseng to help with symptoms such as hot flushes and sleep disturbance. Most clinical studies have failed to demonstrate a major effect of these preparations on symptom relief.

The British Menopause Society recently issued guidance² on alternative and complementary therapies. They state that choice is confusing, that evidence from scientific trials that alternative and complementary therapies improve menopausal symptoms or have the same benefits as hormone replacement therapy (HRT) is poor, that there are concerns over quality of control of production, and that treatments taken this way may interact with prescribed medications with potentially serious consequences.