Menopause in Practice: A Pharmacist’s Guide to HRT, Sleep, Supplements and Safe Care

Source: Irish Pharmacy News, May 2026, pages 20–21.

Dr Aoife Nic Shamhráin, GP and Menopause Specialist at Rose Clinic, Bray, believes pharmacists are uniquely positioned to support women through this stage — but only if they feel confident navigating the nuances of Hormone Replacement Therapy (HRT), supplements, and symptom management.

Menopause is one of the most common yet complex transitions women will experience, and increasingly, community pharmacists are finding themselves on the frontline of care. From managing prescriptions and advising on over-the-counter options, to identifying when something doesn’t quite add up, pharmacists play a critical and often under-recognised role.

“Sometimes, the most powerful thing a pharmacist can do isn’t dispensing — it’s recognising patterns, validating concerns, and guiding women towards the right care,” she says.

HRT: Effective, Safe — But Only When Used Correctly

HRT remains the gold standard for treating menopausal symptoms. When appropriately prescribed, it is both safe and highly effective. However, as Dr Nic Shamhráin highlights, the real-world challenge lies not in prescribing — but in correct use.

“Pharmacists play a key role in ensuring safe use, adherence, and early identification of issues,” she explains.

Women on HRT should be reviewed by their GP or menopause specialist every 6–12 months, but pharmacists often encounter practical issues long before that.

Common issues seen in pharmacy

• Patches not adhering properly (with patients improvising using tape)
• Incorrect use or storage of gels and sprays
• Confusion between cyclical and continuous regimens
• Micronised progesterone (e.g. Utrogestan) taken in the morning — causing avoidable drowsiness

“These are small but important details that can significantly affect outcomes,” she says.

The Critical Role of Progestogen

One of the most important — and sometimes overlooked — aspects of HRT is ensuring adequate progestogen protection in women with a uterus.

“Pharmacists are in a strong position to identify missed doses, incorrect timing, or incomplete regimens,” Dr Nic Shamhráin notes.

This is not a minor issue. Without appropriate progestogen, women are at increased risk of endometrial hyperplasia — a potentially serious complication.

“If there’s any uncertainty around dosing or regimen, pharmacists should not hesitate to contact the prescriber,” she advises.

An Underused Treatment: Vaginal Oestrogen

One of the most impactful yet underutilised treatments in menopause care is vaginal oestrogen.

“It’s incredibly effective, safe for long-term use, and has minimal systemic absorption,” says Dr Nic Shamhráin.

It is particularly beneficial for:

• Genitourinary symptoms
• Vaginal dryness
• Recurrent urinary symptoms
• Even breastfeeding women in some cases

A typical regimen involves daily use for two weeks, followed by maintenance dosing two to five times per week.

“Pharmacists should be actively recommending and discussing this with suitable patients — it can make a huge difference to quality of life.”

Drug Interactions: Fewer Than You Might Think

Reassuringly, HRT has relatively few significant drug interactions. However, caution is needed — particularly when it comes to unregulated products.

“Herbal supplements and compounded HRT are where the real risks lie,” she explains. “Potency, purity and interactions can be unpredictable.”

Pharmacists should remain vigilant and ensure:

• Correct regimens are followed
• Products are used appropriately
• Misuse (e.g. vaginal oestrogen for cosmetic purposes) is avoided

Supplements and ‘Natural’ Remedies: A Grey Area

Many women turn to supplements before, alongside, or instead of HRT — often at considerable cost and with mixed results.

“Very few complementary therapies have robust evidence,” says Dr Nic Shamhráin. “And importantly, ‘natural’ does not mean safe or effective.”

Commonly used supplements include:

• Black cohosh – may offer slight relief for hot flushes but carries risk of side effects and interactions
• Phytoestrogens (soy, red clover) – variable evidence and not suitable for all groups (e.g. breast cancer patients)
• St John’s Wort – can help mood but has significant drug interactions

How pharmacists should approach this

Rather than dismissing these choices, Dr Nic Shamhráin recommends a balanced, empathetic approach:

• Validate the patient’s preference for natural options
• Provide clear, evidence-based information
• Explain that HRT remains the most effective treatment
• Highlight non-hormonal alternatives where appropriate

“Patients need guidance, not judgement,” she says.

Sleep and Fatigue: The Hidden Burden of Menopause

Sleep disturbance is one of the most common and debilitating symptoms of menopause, affecting up to 40–56% of women.

“It’s a major clinical issue — and often multifactorial,” Dr Nic Shamhráin explains.

What’s driving it?

• Declining oestrogen levels
• Night sweats and hot flushes
• Mood changes and stress
• Underlying conditions such as:
• Restless legs syndrome (often linked to iron deficiency)
• Sleep apnoea

What Actually Works?

First-line (often overlooked)

• Sleep hygiene measures
• Cognitive Behavioural Therapy for Insomnia (CBT-I) — one of the most effective long-term treatments

Digital tools such as Sleepio or HSE-supported platforms like Silvercloud can be useful.

Hormonal approaches

HRT can significantly improve sleep:

• Directly through neurological effects
• Indirectly by reducing vasomotor symptoms

The choice of progestogen also matters:

• Micronised progesterone may have a beneficial effect on sleep

Non-hormonal options

For some women, alternatives may be required:

• SSRIs / SNRIs
• Gabapentin
• Clonidine

New and emerging treatments

A particularly exciting development is the emergence of Neurokinin receptor antagonists, such as:

• Fezolinetant (Veoza)
• Elinzanetant (in development)

“These target central thermoregulation pathways and can reduce night sweats — with potential added benefits for sleep,” Dr Nic Shamhráin explains.

What Can Pharmacists Realistically Recommend?

In everyday practice, pharmacists can make a meaningful difference through practical advice:

• Reinforce sleep hygiene
• Screen for underlying issues (e.g. iron deficiency, sleep apnoea)
• Suggest simple, low-risk interventions

Interestingly, some advice is surprisingly simple:

“Two kiwis before bed has evidence behind it,” she notes.

Magnesium is another commonly used supplement:

• Limited evidence
• Low risk
• Some patients report benefit

“Be honest about what we know — and what we don’t,” she adds.

When HRT Isn’t Enough

If a patient remains significantly fatigued despite being on HRT, this should not automatically lead to dose escalation.

Instead, it should prompt further investigation.

“Think broader,” says Dr Nic Shamhráin.

Possible causes include:

• Anaemia
• Thyroid dysfunction
• Sleep disorders
• Mental health issues

New Directions in Menopause Care

Menopause management is evolving rapidly, with a move towards more personalised treatment.

Key trends include:

• Individualised HRT regimens
• Increased use of transdermal HRT (lower VTE risk)

The role of contraceptives

Some newer contraceptive options are also finding a place in menopause care:

• Drovelis (combined oral contraceptive)
• Contains estetrol (a “natural” oestrogen)
• Potentially lower VTE risk profile
• Slinda (drospirenone-only pill)
• Can be used as the progestogen component of HRT (per new BMS guidance)
• Taken continuously
• May offer benefits for PMS/PMDD

“These developments are important for pharmacists to be aware of,” she notes.

When to Refer: Key Red Flags

Pharmacists are often the first point of contact — making recognition of red flags essential.

Urgent referral

• Postmenopausal bleeding
• New breast symptoms
• Persistent pelvic pain

Routine referral

• Ongoing symptoms despite treatment
• Significant fatigue
• Side effects or unclear regimens

Common Misconceptions

Despite growing awareness, several misconceptions persist:

• “Natural” equals safe
• Supplements are always effective
• HRT is inherently risky
• Menopause is not considered as a cause of vague symptoms

“These misconceptions can delay appropriate treatment,” Dr Nic Shamhráin warns.

A Final Thought: The Pharmacist’s Role

For Dr Nic Shamhráin, the key message is simple but powerful:

“Listen to women — and think menopause early.”

Many women present repeatedly with:

• Fatigue
• Poor sleep
• Low mood
• A general sense of “not feeling like themselves”

“Pharmacists are uniquely placed to recognise these patterns, validate concerns, and guide women towards evidence-based care,” she says.

“In many cases, that intervention is more powerful than anything you dispense.”

Further Resources

• British Menopause Society (BMS)
• Women’s Health Concern
• Menopause Society of Ireland
• HSE Silvercloud (CBT support)