Alternatives to HRT

  • Lifestyle – [aerobic exercise, such as regular swimming or jogging] [wearing lighter-weight clothing, sleeping in a cooler room, and reducing stress] [Reduce caffeine]
  • SSRIs [paroxetine, fluoxetine, escitalopram and citalopram] – reduce hot flushes
  • Vaginal lubricants [Vagisil] – reduces dryness
  • Gabapentin – reduces hot flushes
  • Clonidine – no good evidence
  • Complementry therapy – no good evidence
  • on alternatives to HRT


  • Pregnancy and breast-feeding
  • Undiagnosed abnormal vaginal bleeding
  • VTE
  • Active or recent angina or MI
  • Suspected, current or past breast cancer
  • Endometrial cancer or other oestrogen-dependent cancer
  • Active liver disease with abnormal LFTs
  • Uncontrolled hypertension


  • Breast Cancer
    • Only if > 5y use
    • Lifetime risk if >50’s is 10% – this risk is increased by 2.3% every year on HRT
    • @ 5 years – an extra 2 per 1000
    • @ 10 year – an extra 6 cases
    • @ 15 years – an extra 12 cases
  • Endometrial Cancer
    • Oestrogen-only increases risk if uterus intact – GIVE COMBINED HRT IF UTERUS INTACT
    • A minimum of 10 days of progestagen a month reduces this risk to background.
  • VTE
    • Background risk is 1 per 10,000 women per year
    • HRT use increases this to 3 per 10,000 women per year

HRT Choice


  • Oral – [Permarin E3 0.3/0.625/1.25] [Prognova E1 1mg/2mg] [Zumenon E2 1mg/2mg] [Elleste Solo 1mg/2mg]
  • Patch (if liver disease or SE on oral) – [Evorel E2 25/50/75/100mcg] [Estradot E2 25/37.5/50/75/100mcg] [Femseven E2 50/75/100mcg]

No hysterectomy

[Within 12 month of last period] OR [would prefer monthly withdrawal bleed] OR [Is perimenopausal] – Give sequential HRT

  • Oral – [Premique Cycle E3 0.625mg:P4 10mg] [Prempak – C (E3 0.625:P2 75mg) (E3 1.25mg:P2 75mg)] [Ellest Duet E2 (1mg:P1 1mg) (E2 2mg:P1 1mg)] [Femoston E2 (1mg:P3 10mg) (E2 2mg:P3 10mg)]
  • Patch (if liver disease or SE on oral) – [Evorel Sequi E2 50mcg: P1 170mcg]

Else… continuous combined

  • Oral – [Premique Low Dose E3 0.3mg:P4 1.5mg] [Premique E3 0.625mg:P4 5mg] [Femoston Conti E2 1mg:P3 5mg] [Indivina (E1 1mg:P4 2.5mg) (E1 1mg:P4 5mg) (E1 2mg:P4 5mg)] [Kliovance E2 1mg:P1 0.5mg – Kelofem E2 2mg:P1 1mg]
  • Patch (if liver disease or SE on oral) – [Evorel Conti E2 50mcg: P1 170mcg] on HRT choices