Are your menopause symptoms severe enough for HRT?

The Study of Women's Health Across the Nation (SWAN) found that vasomotor symptoms last a median of 7.4 years. Approximately 25-30% of women experience symptoms for more than 10 years. There is no way to predict duration at the outset, which is why ongoing symptom assessment is useful for tracking change over time.

For women who cannot or choose not to take HRT: cognitive behavioural therapy (CBT) has good evidence for managing hot flushes and mood symptoms (NICE recommends it). Regular exercise, maintaining a healthy weight, and reducing alcohol can reduce severity. Prescription non-hormonal medications such as venlafaxine and gabapentin have evidence for vasomotor symptoms. Vaginal moisturisers help with urogenital symptoms.

For most women under 60 or within 10 years of menopause onset, the benefits of HRT outweigh the risks. The British Menopause Society and NICE both note that the original 2002 WHI study headlines overstated risk. The excess breast cancer risk associated with combined HRT is approximately 1 extra case per 1,000 women per year of use. Modern body-identical (micronised) progesterone and transdermal oestrogen are associated with lower risks than older synthetic formulations. Individual risk depends on personal and family medical history, which is why an HRT decision should always be made with a GP or menopause specialist. (Sources: BMS; NICE NG23; WHI reassessment, JAMA, 2013.)

The Greene Climacteric Scale is a validated 21-item questionnaire developed by Dr John Greene in 1998 to measure the severity of menopausal symptoms. It covers five domains: anxiety (6 items), depression (5 items), somatic symptoms (7 items), vasomotor symptoms (2 items: hot flushes and night sweats), and sexual function (1 item). Each item is scored 0-3, giving a total possible score of 63. It is widely used in clinical research and practice to assess symptom burden and track changes over time, including response to treatment. (Sources: Greene, Maturitas, 1998; NICE NG23.)

NICE guideline NG23 (2015, updated 2023) recommends that healthcare professionals should offer HRT as a first-line treatment for vasomotor symptoms (hot flushes and night sweats) and should consider it for low mood related to menopause. It states that the benefits of HRT generally outweigh the risks for women under 60 or within 10 years of menopause onset. NICE also recommends that women should be given clear information about benefits and risks so they can make informed decisions. CBT is recommended for mood symptoms and anxiety. Vaginal oestrogen is recommended for urogenital symptoms regardless of whether systemic HRT is used. (Sources: NICE NG23, 2023.)

The average age of menopause (defined as 12 consecutive months without a period) in the UK is 51. Perimenopause, the transition phase when symptoms often begin, can start in the early to mid-40s. Some women experience symptoms as early as their late 30s. Premature menopause (before 40) affects approximately 1% of women, and early menopause (before 45) affects approximately 5%. Both carry additional health considerations, including increased osteoporosis and cardiovascular risk, and HRT is generally recommended at least until the average age of natural menopause. (Sources: NHS; NICE NG23; BMS.)

Yes. The Greene Climacteric Scale is designed to capture symptoms across the full menopausal transition, including perimenopause. Many women experience their most disruptive symptoms during perimenopause, when hormone levels are fluctuating unpredictably. You do not need to have stopped your periods to use this quiz or to discuss HRT with your GP. NICE guidelines are clear that treatment decisions should be based on symptoms, not blood test results (FSH testing is not recommended for diagnosing menopause in women over 45 with typical symptoms). (Sources: NICE NG23; Greene, 1998.)

Despite NICE guidelines recommending HRT as a first-line treatment, some GPs remain hesitant due to outdated concerns about breast cancer risk from the 2002 WHI study, lack of menopause-specific training, or uncertainty about prescribing for complex cases. A 2021 BMS survey found many GPs felt inadequately trained in menopause management. If your GP is reluctant to discuss HRT, you can request a referral to an NHS menopause clinic, seek a GP with a special interest in menopause, or consult the BMS "Find a Menopause Specialist" directory. You are entitled to an informed discussion about the full range of treatment options. (Sources: BMS; NICE NG23.)