In short
- Treatment is chosen by symptom, not by a single prescription for everything.
- Systemic oestrogen for flushes, the most effective option there is.
- Local oestrogen for dryness and urinary symptoms, which affect about half of women and do not resolve on their own.
- Sleep and mood get their own treatment, because hormones do not fix everything.
- Bone and cardiovascular health reviewed at the same time, since the risk profile changes after menopause.
Treatment Overview
Treatment is matched to the symptom
That sounds obvious and it is frequently not what happens. Different symptoms respond to different things.
| Symptom | First line treatment |
|---|---|
| Hot flushes and night sweats | Systemic oestrogen, the most effective treatment available |
| Vaginal dryness, discomfort with sex, urinary symptoms | Local vaginal oestrogen, which works where it is applied |
| Broken sleep | Depends on the cause. Flushes, sleep apnoea, restless legs and mood are all treated differently |
| Low mood and anxiety | Assessed properly. Hormone therapy is not an antidepressant |
| Bone loss | Systemic therapy reduces osteoporotic fractures, with specific bone treatment where fracture risk is high |
| Cannot take hormones | Cognitive behavioural therapy, certain SSRIs and SNRIs, gabapentin, oxybutynin, or newer targeted medicines |
The two symptoms that behave differently
- Flushes settle eventually for most women, though the median total duration is 7.4 years and around 9 in 100 still have them at 72.
- Vaginal and urinary symptoms do not settle. They affect around half of menopausal women, arrive later than flushes, and tend to worsen without treatment.
That distinction matters when deciding whether to treat now or wait.
What systemic treatment looks like here
Regulated body identical therapy: transdermal oestradiol as a patch, gel or spray, with micronised progesterone where you still have a uterus.
The route is chosen deliberately. Transdermal oestrogen showed no excess clot risk in meta-analysis, even in women with a clotting mutation or a high body mass index, while oral oestrogen does raise it.
The full risk and benefit figures are on the hormone replacement therapy page.
Local treatment, which is under used
Vaginal oestrogen treats dryness, discomfort and urinary symptoms locally. Because absorption into the bloodstream is minimal, many women who cannot or prefer not to take systemic therapy can still use it.
It is one of the most effective and least prescribed treatments in this whole field.
The long term half of the appointment
After menopause, cardiovascular and bone risk change. That means blood pressure, lipids and glucose reviewed, fracture risk considered, and screening for breast and cervix confirmed and kept current.
Hormone therapy is not used to prevent heart disease. These things are treated on their own merits.
Who Is a Good Candidate?
- Your periods have stopped and flushes, sleep or mood are affecting your life.
- You have vaginal dryness, discomfort with sex or recurrent urinary symptoms.
- You want treatment aimed at the symptom that actually bothers you most.
- You cannot take hormones and want the alternatives that have evidence.
- You want your bone and cardiovascular risk reviewed at the same time.
- You have bleeding after twelve months without a period. That is investigated before any treatment.
- You have had breast cancer, where hormone decisions need specialist input.
- You are 65 or older and have never taken HRT, where starting is advised against.
- You want compounded bioidentical hormones or hormone level monitoring to guide dosing.
What Happens During the Consultation
-
1
Which symptom matters most
Flushes, sleep, mood, dryness, libido or joint pain, ranked by what is actually costing you. That ranking decides where treatment starts, and it is asked rather than assumed.
-
2
History and risk
Personal and family history of breast cancer, clots, stroke and heart disease. Migraine, liver disease, previous surgery, blood pressure, weight and smoking. Screening status for breast and cervix.
-
3
The relevant tests
Thyroid function and full blood count with ferritin, because both imitate this. Lipids and glucose as part of the long term picture. Hormone levels are not used to make the diagnosis or set the dose.
-
4
A plan by symptom
Systemic therapy, local therapy, non hormonal options or a combination, with the absolute numbers for your age. Plus separate plans for sleep and mood if those are dominant, and a review at three months.
Program Structure & Follow-Up
The first three months
- Flushes usually improve within a few weeks.
- Irregular bleeding and breast tenderness are common early and settle. Bleeding that continues beyond that is investigated.
- Local vaginal treatment takes a few weeks to work and is then continued long term, because symptoms return when it stops.
Review schedule
- Three months after starting, for symptom control, bleeding, side effects and blood pressure.
- Then annually, as a proper review rather than a repeat prescription.
- Screening confirmed and kept up to date through the right service.
- Bone density considered where fracture risk is raised.
How long treatment continues
There is no fixed stopping date. Given that flushes last a median of 7.4 years, many women are still symptomatic when a defined course ends, and that is planned for rather than discovered.
The decision is revisited annually against your symptoms, your age and how long you have been on treatment. Local vaginal treatment is generally continued for as long as the symptoms would otherwise return.
Benefits, Limits & Safety
What treatment achieves
- Flushes and night sweats, effectively.
- Vaginal dryness, discomfort and urinary symptoms, which respond very well to local oestrogen.
- Sleep, where flushes are the cause.
- Fewer osteoporotic fractures on systemic therapy.
- Lower all cause mortality in the trial data for women starting in their fifties.
The limits
- Hormone therapy is not a treatment for depression, sleep apnoea or thyroid disease.
- Joint pain and memory symptoms have a less clear link to menopause and are assessed separately.
- It is not used to prevent heart disease.
- Symptoms usually return when treatment stops, particularly vaginal symptoms.
When to contact the practice
- Bleeding that continues beyond the first few months, or new bleeding after it settled.
- A new breast lump or change.
- Calf swelling or pain, sudden breathlessness or chest pain.
- New or worsening migraine with aura.
What responds to what
Systemic oestrogen for flushes, local oestrogen for vaginal and urinary symptoms, and separate treatment for sleep and mood. Matching treatment to symptom is what makes the difference.
How you are followed
Review at three months for symptoms, bleeding and blood pressure, then annually. Screening kept current, bone density considered where fracture risk is raised.
When systemic therapy is not used
Breast or other oestrogen dependent cancer, unexplained bleeding, active liver disease, untreated clot or stroke history, and first starting at 65 or older.
Cost & Program Investment
Cost depends on which treatments are appropriate and the follow up they need, so a single number on a website would be misleading. You get the full figure in the consultation before anything is prescribed, and there are no charges you have not been told about.
Frequently Asked Questions
No. Treatment is matched to the symptom. Local vaginal oestrogen, non hormonal medicines with trial evidence, and treatment aimed at sleep and mood are all legitimate routes depending on what is bothering you.
Systemic oestrogen. Nothing else matches it. Where it is not appropriate, cognitive behavioural therapy, certain SSRIs and SNRIs, gabapentin, oxybutynin and newer targeted medicines are the options with evidence.
Local vaginal oestrogen, which works where it is applied with minimal absorption into the bloodstream. Many women who cannot take systemic therapy can still use it, and it is one of the most under prescribed treatments in this field.
No. Unlike flushes, genitourinary symptoms tend to persist and worsen without treatment, and they affect around half of menopausal women. Waiting is not a strategy that works for this one.
There is no fixed stopping date. Flushes last a median of 7.4 years, so many women are still symptomatic when a defined course ends. The decision is reviewed annually against your symptoms and your age.
It can where the mood change is genuinely linked to the transition, particularly alongside flushes and disturbed sleep. It is not an antidepressant, and depression is treated as depression.
Systemic therapy reduces osteoporotic fractures. Where your fracture risk is high, specific bone treatment is used alongside rather than relying on hormone therapy for it.
It is not used for that. In women starting within ten years of menopause there was no excess coronary risk and possibly a reduction, but hormone therapy is not recommended to prevent heart disease.
Because tablet oestrogen raises clot risk while transdermal did not show an excess in meta-analysis, even in women with a clotting mutation or a high body mass index.
Irregular bleeding is common in the first few months and settles. Bleeding that continues beyond that, or new bleeding after it had settled, is investigated rather than accepted.
Hormone options are limited and that decision needs specialist input. What can usually be discussed are the non hormonal treatments for flushes and, in some cases and with oncology agreement, local vaginal treatment.
It depends on which treatments are appropriate and the follow up required, so a single figure would be misleading. You get the full cost in the consultation before anything is prescribed.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.