NB: only metformin and insulin are known to be safe in pregnancy; all drugs should be temporarily discontinued in ketoacidosis; metformin should be temporarily discontinued in lactic acidosis, perioperatively, and if using iodinated contrast agents.
Systemic (for systemic symptoms, e.g. vasomotor): usually transdermal oestorgen (e.g. gel or patch) – women with a uterus on transdermal oestrogen preparations must still take progesterone separately as discussed below
Vaginal oestrogen (for local symptoms, e.g. urogenital atrophy, vaginal dryness): tablet, cream, pessary or vaginal ring
Types of systemic therapy
No uterus → oestrogen-only HRT (usually transdermal, i.e. gels or patches)
Uterus present (oestrogen as above but also need progesterone, usually as oral micronised progesterone, e.g. utrogestan)
Perimenopausal → cyclical HRT (oestrogen given every day, and progesterone given for 12 days of each 28 day cycle – to induce bleed)
Post-menopausal (i.e. no periods for >1 year or been on cyclical HRT for >1 year) → continuous combined HRT(continuous oestrogen and progesterone – no bleed)
NB: the Mirena coil can also suffice as the progesterone component.
Contraindications: undiagnosed PV bleeding, pregnancy/breastfeeding, oestrogen-dependent cancer, active liver disease, uncontrolled hypertension, history of breast cancer, history of venous thromboembolism, recent stroke/MI/angina
Side effects: vaginal bleeding, premenstrual syndrome, breast tenderness, leg cramps, nausea/bloating
Long-term risks: increased VTE risk (except transdermal preparations), increased stroke risk, increased breast cancer risk with time, increased ovarian cancer risk if used >5 years, increased endometrial cancer risk (but only with unopposed oestrogen), coronary artery disease (if started >10 years after menopause)
Treat cause where possible
Diuretic (e.g. furosemide, bumetanide) if fluid overloaded
Treatments with prognostic benefit for heart failure with reduced ejection function (use all)
ACE inhibitor or angiotensin receptor-neprilysin inhibitor (e.g. sacubitril/valsartan)