Hormone replacement therapy

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Background knowledge on HRT

Indications and contraindications 

• Indications
  • Treatment of menopausal symptoms (when benefit outweighs risk)
  • Treatment of early menopause (until natural menopause age ~ 51 years)
  • Osteoporotic fracture prophylaxis in women <60 years (when non-oestrogen containing treatments are unsuitable)
• Contraindications 
  • Current conditions
    • Undiagnosed PV bleeding
    • Pregnancy/breastfeeding
    • Oestrogen-dependent cancer 
    • Acute liver disease
    • Uncontrolled hypertension
  • Historical conditions
    • History of breast cancer
    • History of venous thromboembolism (transdermal HRT may still be considered)
    • Recent stroke/MI/angina

Risks and benefits

• Short-term benefits – relief of:
  • Vasomotor symptoms
  • Psychological symptoms (anxiety, low mood)
  • Reduced libido
  • Urogenital atrophy – use vaginal HRT if symptoms are primarily urogenital
• Long-term benefits
  • Reduction in osteoporosis (and related fractures)
  • Possible reduced risk of colorectal cancer (with combined HRT)
• Risks
  • Venous thromboembolism (significantly lower risk with transdermal therapy)
  • Stroke
  • Breast cancer (small increase in risk, higher with combined HRT)
  • Ovarian cancer (small increase especially if used >5 years)
  • Endometrial cancer (only if women with uterus take oestrogen-only HRT – this is why oestrogen-only HRT is only used in women with no uterus)
  • Coronary heart disease (if started >10 years after menopause)
• Side effects
  • Oestrogen: breast tenderness, leg cramps, nausea/bloating
  • Progesterone: premenstrual syndrome
  • Bleeding: PV bleeding occurs towards end of progesterone phase of cyclical HRT

Types of HRT

• Routes of administration
  • 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.

Duration of HRT

• No maximum duration – individualise according to risks and benefits for each patient
• Risks increase after age of 65

HRT counselling

First ask a few questions (screen for contraindications) 

‘First, I need to ask a few questions to find out if HRT is appropriate for you…’

• Age (menopause usually occurs 45-55 years)
• Confirm menopause if possible
• Discuss their symptoms (and their effect on quality of life)
• PV bleeding
  • Still having periods: ask their regularity
  • No longer having periods: last menstrual period, any post-menopausal/post-coital bleeding
• Relevant past medical history and family history
  • PE/stroke/MI/angina
  • Oestrogen-dependent cancer (breast/endometrial/other)
  • Do they have their uterus? (i.e. no previous hysterectomy) 

What they know already

• Find out what they know about HRT
• Ask if there is anything in particular they want to know
• Explain what you would like to do (discuss what HRT is, the risks and benefits, types of HRT, and also talk about contraception if appropriate)

What HRT is and why it is used

• Explain what the menopause is
  • The time when menstrual periods cease and a woman is no longer able to get pregnant
  • It occurs because the ovaries run out of follicles, and this results in reduced production of oestrogen by the ovaries
  • Oestrogen plays a major role in regulating the female reproductive system, but also has many other effects on the body, e.g. mood, libido
  • Symptoms last for 4 years on average (but can be up to 12)
• Explain how HRT treats the symptoms
  • HRT replaces oestrogen ± progesterone 
• Benefits of HRT 

Risks and benefits

• Discuss both and take care to explore and address patient’s concerns
• Outline major side effects

Discuss types of HRT

• Explain how HRT is given
• Explain routes of administration 

Briefly mention contraception

• Women are potentially fertile for 1 year after last menstrual period (or 2 years if <50 years)
• Explain HRT is not contraception
• Contraceptive options for women on HRT
  • Barrier methods
  • Progesterone only pill (in addition to HRT)
  • Mirena coil (can be used as progesterone component of HRT)

Ending

• Summarise
• Let patient think about it and plan follow-up
• Offer leaflets/website links

Test your knowledge – what are some alternatives to HRT for the following symptoms?

Low mood

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Vasomotor symptoms

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Vaginal dryness

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Irregular periods

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