Updated 24 July 2006

We do not recommend routine replacement therapy. There are some postmenopausal symptoms which can cause considerable distress to patients and the issue of replacement therapy needs to be considered.

1. Hot Flushes: initially try counseling, time. Avoidance of triggers for hot flushes may be helpful and include avoidance of caffeine (coffee or tea), chocolate, alcohol, colas, stress, hot weather. Medications that have been shown to be effective for some women include Effexor (lowest effective dose of 37.5 mg/day) clonidine (Dixarit 0.05 mg bid), Bellergal. If the symptoms are still severe after 6+ months, the lowest dose of combination estrogen and progesteron or progesterones alone (provera 5 mg or megace 40 mg) may be tried. They should be used at the lowest dose for the shortest duration after a full disclosure of the lack of evidence available for risk and benefit so a woman can make a choice related to quality of life issues.  
2. Vaginal Irritation/Dyspareunia: try non-hormonal, water-soluble lubricants applied directly to the introitus and/or penis. If unsuccessful, using small amounts of estrogen cream (i.e., 1/4 manufacturer's recommended dose) applied topically to the introitus, intermittently, may be helpful. Estrogen used in this fashion is absorbed systemically. The potential risks and benefits should be discussed. Estring, an intravaginal estrogen releasing device, is another option. Serum levels of estrogen are only apparent for 24 hours after the initial use, so this may give a more local effect that may relieve symptoms and have less systemic absorption.  
3. Osteoporosis. There are now a number of options for osteoporosis. Weight bearing exercise, calcium, vitamine D, and bisphosphonates all may improve osteopenia and osteoporosis. Raloxifene has also been licensed for this condition. For the majority of women entering menopause (without a diagnosis of breast cancer) estrogen therapy may be beneficial and carries only a small increased risk of developing breast cancer (1.5x after 10 to 15 years of use) and a small risk of developing endometrial cancer. For women with a diagnosis of breast cancer, tamoxifen may help prevent premature bone mineral loss. Treatment should be individualized.  
4. Heart disease. There is controversy over the role of hormone replacement and the prevention of heart disease. Diet, exercise, avoidance of smoking and monitoring of hypertension, cholesterol etc. may be of major benefit.