Individualise the route according to patient preference, age, symptoms, medical history, comorbidities and contraindications, using the lowest effective dose NICE CKS. Oral HRT is an option when consistent with the patient's preferences and individual risk assessment NICE CKS.
Favour transdermal HRT when any of the following apply: NICE CKS
- Previous or increased risk of venous thromboembolism NICE CKS.
- Cardiovascular risk factors, including obesity, hypertension or hypertriglyceridaemia NICE CKS.
- Migraine or gallbladder disease NICE CKS.
- Impaired gastrointestinal absorption or concomitant hepatic enzyme-inducing medication, such as carbamazepine NICE CKS.
- Persistent symptoms or troublesome adverse effects with oral HRT, or lactose sensitivity because many oral preparations contain lactose NICE CKS.
If continuing HRT beyond age 60, advise transdermal estradiol NICE CKS. Transdermal options include oestrogen-only patches, gel or spray, and combined oestrogen–progestogen patches NICE CKS.
Endometrial protection remains essential with either route: people with a uterus require combined HRT, whereas those without a uterus generally receive oestrogen-only preparations NICE CKS. With transdermal oestrogen, progestogen can be provided separately as an oral preparation or a 52 mg levonorgestrel intrauterine system NICE CKS.
Review periodically to reassess symptom control, tolerability and the benefits and risks of continuing treatment NICE CKS. Seek menopause specialist advice if there are contraindications, a condition that may be affected by HRT, or uncertainty about the most suitable treatment NICE CKS.