Hormone Replacement Therapy

Hormone Replacement Therapy overview chart on A4Medicine presents the general practitioner with a clear description of associated benefits and risks. An initial assessment and examination are followed by a clear list of contraindications. A simplified flow chart helps in choosing the right preparation. Use of transdermal preparations can be suitable in certain circumstances and the clinician can quickly review that. The focus is also on SEs and when to stop treatment. Tibolone is rarely used or initiated in primary care and has not been included in this review of hormone replacement therapy.

HRT benefits and risks-HRT effectively relieves vasomotor symptoms
○ Offer and discuss short term (5 yrs ) and longer term benefits and risks
 Venous thromboembolism ( VTE )

○ Increased risk of DVT/ PE with ORAL HRT
○ Risk is greater for oral than transdermal preparations
○ Consider transdermal rather than oral HRT for menopausal ♀ who are at ↑ed risk of VTE ( including BMI of > 30 )
○ High risk VTE eg strong family hx or thrombophilia → refer for specialist opinion before starting ( eg haematologist )

 Cardiovascular risk

○ HRT does not increase CVD risk when started in ♀ < 60
○ does not affect the risk of dying from CVD
○ presence of CV risk factors is not a CI to HRT as long as they are optimally managed
○ baseline risk of CVD around menopause varies based on presence of CV risk factors
○ Oestrogen alone HRT – associated with NO or REDUCED risk of Coronary heart disease
○ Combined HRT associated with little or NO increase in risk of CHD

Breast cancer

○ Baseline risk around menopause varies -according to presence of underlying risk factors
○ Combined HRT associated with an increased risk 
( 2.7 times more likely than non user )
○ Oestrogen alone HRT–> little or no change in risk of Ca breast
○ Any increase in risk is related to treatment duration and reduces after stopping treatment

Type 2 diabetes

○ No increased risk of developing type 2 diabetes
○ ♀ with type 2 diabetes – HRT not generally associated with an adverse effect on blood glucose control
○ Women with type 2 diabetes- consider HRT after taking co-morbidities into account ( seek specialist adv if needed ) Stroke

○ taking oral but not transdermal oestrogen is associated with a small increase in risk of stroke
○ ♀ < 60 – baseline population risk of stroke is very low Osteoporosis

○ baseline population risk of fragility fracture for ♀ around menopause is low and varies from ♀ to ♀
○ risk of fragility fracture decreased while taking HRT
○ benefit maintained during treatment but decreases once treatment stops
○ benefit may continue for longer in ♀ who take HRT for longer

Age ( average age 51 yrs ) History , symptoms Medications Family history Lifestyle Bleeding – menstrual history
○ post-coital bleeding
○ abnormal bleeding pattern 
( consider further investigations ) Uterus- intact Risk factors for osteoporosis , breast cancer and CHD

Contraindications-Current , past or suspected breast cancer Known or suspected oestrogen sensitive cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasia Previous idiopathic or current venous thromboembolism ( DVT or PE ) unless the woman is already on anticoagulant treatment Active or recent arterial thromboembolism Untreated hypertension Active liver disease and abnormal LFTs Poryphria cutanea tarda Pregnancy Dubin- Johnson and Rotor syndrome

Do not routinely offer
 SSRIs , SNRIs , or Clonidine as first line treatment for vasomotor symptoms High risk patient eg breast cancer , severe liver disease , previous stroke or MI
REFER Sequential 
Combined HRT Continuous 
Combined HRT Oestrogen only HRT usually 
taken continuously Transdermal HRT-If she prefers this route Symptom control is poor with oral treatment Oral treatment causes adverse GI SEs as nausea History or risk of VTE On hepatic inducing enzyme as carbamezapine Underlying bowel disorder which may affect absorption H/O Migraine Lactose sensitivity ( most HRT tablets contain lactose )

Transdermal combined HRT the progestogen is either combined into the patch or given separately as a tablet