Menopause Treatment Options, Side by Side: What Each One Does

"Is it HRT or nothing?" "I've heard the tablets cause clots." "Should I just try a supplement first?"

I hear these a lot. Most women have more options than they were offered: at least 6. Some need a prescription. Some you can start tonight.

So here they are side by side: what each one does, who it may suit, and what to ask about. If you'd like it all in one place, the Your Options guide is free.

HRT: oestrogen through the skin, or as a tablet

What it does. HRT (hormone replacement therapy) replaces the oestrogen your ovaries are making less of. It's used for hot flushes, night sweats, broken sleep, low mood, aching joints and vaginal dryness, and it protects bone density while you're taking it.

The oestrogen in most HRT is oestradiol, which is body-identical: the same molecule your body makes. Through the skin, usually as a patch or gel, it goes straight into your bloodstream. Most tablets are the same body-identical oestradiol, but a tablet passes through the liver first, and that's where the higher clot and stroke risk of tablets comes from. Through the skin is my first choice.

Who it may suit. Most women with symptoms. Started before 60, or within 10 years of your last period, the balance of benefit and risk is generally favourable. A past clot or migraine with aura usually changes the route rather than ruling HRT out. It isn't used while breast cancer is being treated, with an active clot, soon after a heart attack or stroke, with active liver disease, with bleeding that hasn't been checked, or in pregnancy.

What to ask. Is this through the skin or a tablet, and why that one for me?

The progesterone part of HRT, if you have a womb

What it does. Oestrogen on its own thickens the womb lining, which raises the risk of womb cancer. So if you still have your womb, HRT comes with something to protect the lining.

There are 2 kinds. Body-identical progesterone is the same molecule your body used to make. A synthetic progestogen is a changed molecule that acts in a similar way, and it's in most combined patches and tablets and in the hormone-releasing coil. A progestogen is not progesterone, even when it's called that.

The evidence: observational studies link body-identical progesterone with a lower breast cancer and clot risk than most synthetic progestogens, and fewer side effects. It isn't settled. My view: body-identical first. Synthetic progestogens have a place in specific cases, such as the hormonal coil, contraception, bleeding control or endometriosis, but in my view they carry more side effects and more risks than body-identical progesterone, so they are not my first choice.

What to ask. Is the part protecting my womb body-identical progesterone or a synthetic progestogen?

Breast cancer and clots, in numbers

Of 1,000 women aged 50 who don't use HRT, about 13 are diagnosed with breast cancer over the next 5 years. Oestrogen with a progestogen for up to 5 years adds about 3 to 7 to that. Oestrogen on its own, for women without a womb, makes little or no difference. Obesity adds about 10, and drinking 4 to 6 units of alcohol a day adds about 8.

Oestrogen tablets raise the risk of a clot in the leg or lung. Oestrogen through the skin, at standard doses, has not been shown to. Vaginal oestrogen on its own has not been shown to raise breast cancer risk.

Local vaginal oestrogen

What it does. A low dose of oestrogen put right where the problem is, as a cream, pessary or small tablet. It's used for dryness, pain during sex, urgency and repeated urine infections after the menopause. Very little reaches the rest of you.

Who it may suit. Almost any woman with these symptoms after the menopause, on its own or on top of HRT, and it doesn't need the progesterone part at standard doses. Some low-dose vaginal oestrogen can be bought from a pharmacy, for women over 50 who have gone 12 months without a period. After breast cancer, it's decided with your breast cancer team.

What to ask. Could my bladder symptoms be part of this? Give it around 3 months before you judge it. The free Vaginal and Bladder Health guide goes through it in detail.

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3 free guides to keep:

Non-hormonal prescription options

What they do. One newer type is called neurokinin receptor blockers. They're tablets that work on the part of the brain that sets off a hot flush. You need a liver blood test before starting, one of them needs repeat liver tests over the first few months, and they don't suit significant liver problems. Older options include low-dose antidepressants from the SSRI (selective serotonin reuptake inhibitor) and SNRI (serotonin and noradrenaline reuptake inhibitor) classes.

Who they may suit. Women who can't take HRT, would rather not, or are on hormone-blocking treatment after breast cancer. Each has its own side effects, from nausea to drowsiness.

What to ask. Ask about neurokinin receptor blockers by name. If you take a hormone-blocking tablet after breast cancer, ask which options are safe with it.

CBT (cognitive behavioural therapy)

What it does. A talking therapy, with a version made for the menopause. National guidance recommends it for hot flushes, night sweats and the sleep problems that come with them. In trials it reduced how much flushes bothered women and helped sleep, and in one trial the flushes came less often too. It usually takes 4 to 6 weeks, as a self-help book or a group.

Who it may suit. Anyone, alongside HRT or instead of it. For long-standing insomnia, CBT for insomnia is the first treatment to try, before sleeping tablets.

Strength training, sleep and alcohol

Exercise hasn't been shown to reduce how often flushes come, but these matter for everything else. Muscle loss speeds up from the mid-40s, and 2 resistance sessions a week holds on to what you have, as long as the weights get heavier over time.

A fixed wake time, 7 days a week, does more for sleep than a fixed bedtime. Alcohol gets you to sleep and then wakes you at 3am, and for many women it's a hot flush trigger. These suit everyone, from day 1. Strength work takes 6 to 12 weeks to show, so keep going.

Supplements: what the evidence says

No food supplement has good evidence for moderate to severe hot flushes. Black cohosh has inconsistent trial evidence and carries a liver warning: stop it and get checked the same day if your skin or eyes turn yellow, your urine goes dark or you get tummy pain. Choose a pack with a THR (traditional herbal registration) number, and avoid it after breast cancer. National guidance says soy and red clover isoflavones may help a little, but products vary, they interact with other medicines, and they're not for use after breast cancer. Where you're genuinely low, correcting it helps: vitamin D contributes to the maintenance of normal bones and normal muscle function. Food supplements should not replace a varied, balanced diet and a healthy lifestyle.

How you choose, and where to start

The clinic works in this order: talk, start, test, review. Over 45, perimenopause and menopause are diagnosed from your symptoms, so you don't need a blood test first, and where treatment is right for you it can start after the first appointment. Blood tests, such as thyroid, iron, B12 or vitamin D, come in where they help.

A good first step is the free Symptom Tracker, so you bring your pattern on paper.

The Menopause Consultation is 45 minutes online, by video or voice call, wherever you live in the UK. We go through your symptoms and history, and decide together what to start. You can book a Menopause Consultation here. For anything else, like periods, weight, gut, skin or hair, the Women's Health Consultation is the one for you.

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Every Sunday morning I send out my newsletter, Beyond Prescriptions, with 1 women's health lesson and what to do with it. You can sign up here.

Debora Tentis, Women's Health Pharmacist.