Menopause and HRT: change the route, not the decision

Clinical Rounds, the GPAtlas podcast. Women's Health. 19 minutes. Published 31 August 2026. Free to listen.

Clinical source: our own Ocean article "Menopause and Perimenopause", last reviewed 7 May 2026.

Transcript

Sarah: Hello, and welcome to GPAtlas Clinical Rounds. I'm Sarah, and this is the podcast where we take one thing you'll genuinely see this week and work out what to do with it.

Ben: And I'm Ben. Today, menopause, and one idea that turns most of the difficult consultations into easy ones.

Sarah: Karen is fifty-two. Flushes, terrible sleep, and she describes her mood as short-tempered with everybody including herself. Her BMI is thirty-four, she gets migraines, and her mother had a DVT. And she says, I assume I can't have HRT with all that. And a version of me a few years ago would have agreed with her, sympathetically, and offered her an antidepressant.

Ben: Three things. The single idea that unlocks most of these: route, not refusal. What not to test, which is more than you'd think. And the bleeding that has to interrupt everything.

Sarah: So the idea first, because it reframes everything after it. Our article's line is this: where there are cardiovascular or thrombotic risk factors, transdermal oestrogen avoids the venous thromboembolism and stroke signal seen with oral preparations, so the answer is usually a change of route, not refusal.

Ben: And the list of who that applies to is exactly Karen. Transdermal oestrogen, so a patch, gel or spray, is preferred for raised VTE risk, a BMI over thirty, migraine, gallbladder or liver disease, and cardiovascular risk. And our article states it has no excess VTE or stroke risk. So every single one of her reasons for assuming she can't have it is actually a reason to use a patch.

Sarah: And that's a completely different consultation. She came in expecting to be told no, and braced for it. Instead the answer is yes, and here's the form it takes. It also means the migraine question, which in contraception is an absolute stop, is not the same question here at all, and it's worth being clear in your own head which of those two conversations you're in.

Ben: Route, not refusal. A patch answers most of the objections.

Sarah: Now what not to do, which is test her. Our article says to diagnose perimenopause and menopause clinically, without laboratory tests, in otherwise healthy women aged over forty-five with typical symptoms. She's fifty-two with flushes and sleep disturbance. That's the diagnosis. No bloods.

Ben: And the reason isn't cost, it's that the test actively misleads. FSH fluctuates widely from cycle to cycle, so a normal result can falsely reassure and delay treatment. So a woman with textbook symptoms and a normal FSH is worse off than if you'd never taken the blood, because now there's a number in her record arguing against the diagnosis.

Sarah: And there's a second list not to order, which is the one patients sometimes arrive asking for: do not use AMH, oestradiol or antral follicle count. Those come up because they're used in fertility, and they don't answer this question.

Ben: There is one place FSH earns its place, and it's premature ovarian insufficiency. The diagnosis is menopausal symptoms plus two FSH levels above thirty, taken four to six weeks apart. Two samples, spaced, because of that fluctuation. So it's not that FSH is useless, it's that it's useless in the situation where it's most often ordered.

Sarah: Over forty-five with symptoms, no test. Two FSHs if you suspect POI.

Sarah: So what do you actually prescribe. And the first thing our article says is one people still find surprising: offer HRT first-line for vasomotor symptoms and for low mood associated with menopause. So for Karen's short temper and low mood, the first-line drug is HRT, not an SSRI.

Ben: And it's specific about the antidepressants: SSRIs and SNRIs, venlafaxine, escitalopram, are not first-line for flushes alone. With a genuine trap attached, which is avoid paroxetine and fluoxetine with tamoxifen, because they reduce its efficacy. So the woman on tamoxifen after breast cancer, who is the one most likely to be offered a non-hormonal option, is the one where the choice of antidepressant matters most.

Sarah: On the preparation itself, the split is about whether she's still bleeding. Perimenopausal and still bleeding: sequential combined HRT, oestrogen daily with progestogen twelve to fourteen days a month, giving a monthly withdrawal bleed. Postmenopausal: continuous combined, which is bleed-free. And you switch from sequential by age fifty-four, or after five years of use.

Ben: Progestogen options are micronised progesterone, so Utrogestan, which our article describes as body-identical with a favourable side-effect and breast profile, or a fifty- two milligram levonorgestrel coil, which gives endometrial protection and contraception at the same time. And the dose of progestogen must be proportionate to the dose of oestrogen, which is the bit that gets missed when someone's oestrogen is increased and nothing else changes.

Sarah: And one exception that catches people out. After a hysterectomy you use oestrogen alone. Except in endometriosis, where you still add a progestogen. So hysterectomy is not automatically a free pass on the progestogen, and that's worth checking rather than assuming.

Ben: HRT is first-line for the mood too. Not an SSRI.

Sarah: Contraception, which is the thing most likely to catch you out, because HRT feels like it ought to cover it and it does not. Our article is explicit: HRT is not contraceptive, and pregnancy is possible in premature ovarian insufficiency.

Ben: And the timings: contraception is needed until two years after the last period if she's under fifty, and one year if she's fifty or over. So Karen at fifty-two, if her periods stopped eight months ago, still needs contraception, and she almost certainly assumes she doesn't.

Sarah: HRT is not contraception. Ask when her last period was.

Sarah: Now the thing that stops everything else. Any postmenopausal bleeding, meaning any bleeding more than twelve months after the last period, is a suspected endometrial cancer referral on the urgent pathway. That one's absolute and most of us are solid on it.

Ben: Where it gets harder is unscheduled bleeding on HRT, which is common and mostly benign. Our article points to a stratified approach: one or more major risk factors, or three or more minor ones, means stop the HRT and refer on the urgent suspected cancer pathway. So it isn't all reassurance and it isn't all referral, there's an actual rule.

Sarah: And one measurement trap worth knowing so you don't over-read a scan report. There is insufficient evidence for a single endometrial thickness cut-off in women on HRT. The four millimetre reassurance threshold applies to postmenopausal bleeding in women not on sequential HRT. So a thickness of five in a woman on sequential HRT is not the same finding as five in a woman on nothing.

Ben: Any bleeding after twelve months is a two-week wait.

Sarah: Two more things to offer that aren't oestrogen. Menopause-specific cognitive behavioural therapy, which NICE recommended in twenty twenty-four for vasomotor symptoms, low mood and sleep disturbance, alongside HRT or where HRT is declined or contraindicated. That's a genuine treatment now, not a consolation prize.

Ben: And vaginal oestrogen, which is a separate decision from systemic HRT and gets tangled up with it. It can be continued long-term, including alongside systemic HRT, and our article says it's appropriate for many women with a history of breast cancer after specialist discussion. So the woman who cannot have systemic treatment is not automatically excluded from the thing that would fix her urinary symptoms and her discomfort.

Sarah: There's also fezolinetant, Veoza, forty-five milligrams daily, which is non-hormonal. It carries an MHRA warning for liver injury: check liver function at baseline, monthly for three months, then at six and nine months, avoid it in liver disease, and stop for symptoms or transaminases above five times the upper limit of normal. That's a demanding monitoring schedule and it needs to be set up properly at the start.

Ben: And testosterone, if low desire persists despite HRT and other causes are excluded. AndroFeme one per cent cream got a UK licence in August twenty twenty-five for postmenopausal low desire, currently private. Testogel and Tostran are used off-label on the NHS. And the sequencing point: switch oral to transdermal oestrogen first, then review at two to three months, then every six to twelve.

Sarah: CBT is a treatment now. And vaginal oestrogen is a separate decision.

Sarah: Two things about the long run. Premature ovarian insufficiency: offer HRT, or a combined contraceptive, at least until the average age of menopause, around fifty-one, to reduce cardiovascular disease and osteoporosis and to support genitourinary and cognitive health. And our article's framing is the important part: this is hormone replacement, not optional symptom relief.

Ben: And for everyone else, review at three months after starting or changing, then at least annually, checking blood pressure, weight and whether it's working. And the sentence that ends a lot of unnecessary stopping: there is no arbitrary time limit on HRT.

Sarah: On breast cancer risk, so you can answer it honestly rather than deflecting: combined HRT raises breast cancer risk, and that persists about ten years after stopping, while oestrogen-only adds little or none. That's a real risk and it deserves a real conversation, not a reassurance.

Ben: And one interaction that's easy to miss on a repeat list: the levothyroxine requirement may rise after starting oral oestrogen, so recheck the TSH at six to twelve weeks in treated hypothyroidism. That's a woman who becomes newly tired a couple of months after starting HRT, and it looks like the HRT not working.

Sarah: No time limit. And recheck her thyroid if she is on levothyroxine.

Sarah: Let me come back to Karen, because I want to be honest about the shape of that consultation too. She came in having already decided she wasn't eligible. And a lot of women in their early fifties have done exactly that, usually from a mix of what they've read about breast cancer and what a clinician said to them a decade ago when the guidance was different.

Sarah: So the useful move isn't to launch into preparations. It's to find out what she thinks the barrier is, because it's usually one specific thing. Her mother's clot. Her weight. Her migraines. And in her case all three of those point to a patch rather than away from HRT entirely, which means the whole objection resolves into a route choice.

Ben: And the breast cancer question deserves a straight answer rather than a deflection, because if you're vague she'll assume it's worse than it is. Combined HRT raises the risk and that persists about ten years after stopping. Oestrogen-only adds little or none. So the honest answer depends on whether she's had a hysterectomy, and for her, with a uterus, it's the combined figure that applies.

Sarah: And then the counterweight, which is that there's no arbitrary time limit on HRT, and the review is annual rather than a countdown to stopping. A lot of women are quietly waiting to be told to stop, and being told that there isn't a fixed endpoint changes how they think about starting.

Ben: Find the specific objection. It usually resolves into a route.

Sarah: And the thing I'd most want to leave people with is the sequence, because it's short. Over forty-five with typical symptoms: no test. Risk factors: change the route, not the decision. Still bleeding: sequential. Has a uterus: add a progestogen, and remember endometriosis after hysterectomy. And any bleeding twelve months after her last period is a two-week wait, whatever else is going on.

Ben: With one addition that catches people at the end of the consultation: she still needs contraception. Two years after the last period if she's under fifty, one year if she's fifty or over, everything stops at fifty-five, and HRT does not count. That's the question most likely to be forgotten because the appointment felt finished.

Sarah: No test, change the route, and she still needs contraception.

Ben: Two practical additions on preparations that come up when you actually write the prescription. The progestogen dose must be proportionate to the oestrogen dose, so if you increase her oestrogen, the progestogen needs looking at in the same consultation rather than left as it was.

Ben: And the coil counts. A fifty-two milligram levonorgestrel intrauterine device gives endometrial protection and contraception at the same time, and our article notes it's supported for five years for endometrial protection. For a woman who also needs contraception, which is most women in Karen's position, that solves two problems with one device.

Sarah: Change the oestrogen, look at the progestogen. And the coil does both jobs.

Ben: Exam corner. A fifty-two year old woman has hot flushes, poor sleep and low mood. Her BMI is thirty-four, she has migraine without aura, and her mother had a deep vein thrombosis. She has not had a hysterectomy and her last period was eight months ago. What is the most appropriate management? A, an SSRI, given her risk factors. B, check FSH before deciding. C, sequential combined HRT using transdermal oestrogen. Or D, continuous combined HRT using oral oestrogen.

Ben: It's C. Her BMI, her migraine and her family history are all indications for the transdermal route rather than reasons to withhold HRT, which is the change-the-route principle. She's still within twelve months of her last period, so she's perimenopausal and needs a sequential preparation, and she has a uterus so she needs a progestogen. A is wrong because HRT is first-line for menopausal low mood. B is wrong because she's over forty-five with typical symptoms, so you diagnose clinically. And D is the wrong route and the wrong regimen for someone still bleeding.

Sarah: So. Three things for Monday. One. Risk factors change the route, not the decision. Obesity, migraine and thrombotic risk all point to a patch. Two. Over forty-five with typical symptoms, don't test, because a normal FSH will mislead you. And three. HRT is not contraception, so ask when her last period was, and remember two years under fifty, one year over.

Sarah: One thing to reflect on, if you're logging this. Think about the last woman you told she couldn't have HRT. Was it actually a reason to use a patch instead? The full transcript and the references are on the episode page. Ben and I are synthetic voices. The medicine isn't. See you next week.

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