Yorkshire Menopause Group
HRT Management




Pre-treatment assessment


Full history to include discussion of benefits and risks prior to starting HRT. Warn of side effects which may settle within first 3 months - avoid altering treatment during this time. Encourage breast awareness.

Examination :- Height, weight, BP.
Consider pre-treatment mammogram - especially in women with family history of breast cancer *1
Consider bone density scan (DEXA) *2

Preferred routes of oestrogen administration

Vaginal symptoms
Use vaginal therapy.
3 months use of vaginal oestrogen is associated with a very low risk of endometrial stimulation. Longer use, particularly with dienoestrol or conjugated equine oestrogen preparations, is associated with increased risk, and may require the use of a progestogen.
Systemic symptoms
In general, there is no evidence of increased benefit of one route of administration over another. For compliance, patient choice is the most important determinant. Transdermal preparations (avoiding the first pass metabolism) are, however, preferred in women with a history of;

  • Hypertension

  • Gallstones

  • Thrombo-embolic disease

  • Epilepsy

  • Liver disease

  • Malabsorption

  • Migraine

  • Diabetes

  • Hypertriglyceridaemia

Patient review

  1. 3 months - Discuss bleeding pattern , symptom control, side effects & alter dosage as necessary *3
    Check BP

  2. 6 months - As 3 months
    Patients on implants are at risk of tachyphylaxis; whilst this is rare, good practice would include a pre-implant oestradiol level and replacement avoided within 6 months, to reduce this risk

  3. Every 12 months - as 3 months, plus BP & weight

  4. Mammography to be repeated according to NHS breast screening programme

Treatment duration

  • Symptom relief
    3-5 years followed by gradual withdrawal; continue treatment if symptoms recur

  • Osteoporosis*
    5-10 years (longer after discussion with patient)

  • Premature menopause
    Treat to the average age of menopause (51) and review benefits vs. risks of continuing treatment (increased risk of breast cancer applies only after the average age of menopause)

Contraception

HRT is not contraceptive.
Contraception should be continued for 2 years after the menopause occurring under 50 years and 1 year over 50 years. If HRT is started pre-menopausally, the last menstrual period is masked, and fertility status is therefore unclear. Contraception is advisable until the age of 54 , when 80% of women will be post-menopausal.

*1 This is based on local consensus rather than being evidence based
*2 See Leeds Osteoporosis guidelines
*3 See troubleshooting section



Fibroids
Fibroids may increase in size during oestrogen therapy, which may be associated with heavy withdrawal bleeding. HRT may be started and bleeding problems managed as in the troubleshooting guide. Referral should be considered if fibroids continue to increase in size and are causing symptoms. Patients should be counselled appropriately.

Hypertension
Pre-existing hypertension is not a contra-indication, but must be controlled before HRT commenced. Transdermal route is preferred first line. Conjugated equine oestrogens may be associated with an idiosyncratic rise in BP.
*BP should be reviewed at 3 and 6 months, then annually if stable.

Migraine headaches

  • Long-standing migraines which ease at the menopause may deteriorate on HRT

  • Migraines associated with the menopause may benefit from HRT

  • Transdermal oestrogens are preferred first line therapy

  • There is no data available for focal migraines or migraines with aura - refer to menopause clinic

Endometriosis

  • Oestrogen may reactivate endometriosis. This can be reduced by the use of combined therapy. Commence low dose HRT and review.

  • Continuous-combined HRT is preferable in postmenopausal women and in all women after pelvic clearance.

Family history of breast cancer

  • Little data available. There is no evidence that HRT will increase the risk of breast cancer any further than in women without a positive family history.

  • Breast awareness must be encouraged and pretreatment mammograms considered.