A 51 year old woman presents to her general practitioner with troublesome hot flushes and night sweats for the past eight months. She is sexually active and her last period was about 5 months ago. She has taken a number of over-the-counter preparations, but none have been effective. She is anxious about having hot flushes at work and exhausted from sleep disturbance. She wants advice about managing her symptoms. Menopause is a normal physiological event in women, occurring at a median age of 51 years. Hormone replacement therapy (HRT) contains oestrogen for relieving menopausal symptoms; for women who still have their uterus it is combined with a progestogen for endometrial protection. The oestrogen (oestradiol, oestradiol 17β, oestrone, or conjugated equine oestrogen) can be oral, intravaginal, or transdermal. The progestogen can be oral, transdermal, or delivered via an intrauterine device (Mirena, Bayer Schering). In HRT regimens the oestrogen is taken daily, with progestogen added either sequentially (cyclic regimen) or daily (continuous combined regimen) if it is needed.1 Tibolone is an oral synthetic steroid preparation with oestrogenic, androgenic, and progestogenic actions that can also be used as HRT. Testosterone can be added to HRT, but the role of supplemental testosterone will not be covered in this case. The key indication for HRT or tibolone is the presence of troublesome vasomotor symptoms (hot flushes and night sweats, with or without awakening). Vasomotor symptoms are normal and affect about 80% of women during the menopause transition and are severe in about 20% of these women. The duration of these symptoms varies, with a median of four years, but may continue for as many as 12 years in about 10% of women.2 HRT may be indicated when menopausal symptoms are adversely affecting quality of life. HRT is currently the most effective treatment for …