QuestionSBA
QuestionChoice
This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen.
53081
e
Cyclical oestrogen-only hormone replacement replacement therapy
QuestionChoice
This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen.
53080
d
Continuous oestrogen-only hormone replacement therapy
QuestionChoice
This patient has symptoms in keeping with the menopause that are affecting her quality of life and so is appropriately seeking treatment. Selective serotonin reuptake inhibitors (SSRIs) are not advised as first-line treatments by National Institute for Health and Care Excellence, with HRT providing added benefits such as on bone mineral density. SSRIs may be considered in situations where HRT is contraindicated, such as breast cancer. There are no such contraindications in this case.
53079
c
Selective serotonin reuptake inhibitor
QuestionChoice
This patient has symptoms in keeping with menopause and is of average menopausal age. She is still having periods every 4 months and therefore hormone replacement therapy (HRT) should be given cyclically. She has no risk factors that would contraindicate oral HRT (such as malignancy or venous thromboembolism) and her symptoms are impacting her quality of life significantly. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen and is not keen on an intrauterine system. Therefore a combination HRT is the most appropriate.
53077
a
Cyclical combined hormone replacement therapy
QuestionChoice
This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She has no risk factors that would contraindicate HRT and her symptoms are impacting her quality of life significantly. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen. She is not keen on an intrauterine system; therefore, combination HRT is the most appropriate.
53078
b
Continuous combined hormone replacement therapy
Concept
Chapter
# Summary 
  
 
Hormone Replacement Therapy (HRT) is a treatment strategy used to alleviate menopausal symptoms by replacing diminishing hormones. It typically involves small doses of oestrogen and progestogen (if the woman has a uterus) to reduce endometrial cancer risk. HRT may be administered systemically or vaginally and can help manage symptoms such as flushing, insomnia, headaches, vaginal atrophy, and dryness. However, it may also have side effects including breast tenderness, leg cramps, bloating, nausea, and headaches. Key investigations involve assessing the history and physical examination of the patient to decide the need for HRT. Management strategies include careful dose regulation and monitoring for side effects.
  
 
# Definition 
  
 
Hormone replacement therapy (HRT) is a treatment to relieve symptoms of menopause by replacing hormones that decrease as a woman approaches the menopause. It typically involves small doses of oestrogen combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer.
  
  
 
# Indications 
  
 
  - Symptomatic relief of vasomotor symptoms such as flushing, insomnia, headaches, vaginal atrophy and dryness
  - Decreases the risk of osteoporosis and colorectal cancer
  - In premature ovarian insufficiency, HRT should be continued until the age of 50. This is to help prevent the development of osteoporosis
  
 
# Contraindications
  
 
  - Undiagnosed vaginal bleeding
  - Pregnancy
  - Breastfeeding
  - Oestrogen receptor-positive breast cancer
  - Acute liver disease
  - Uncontrolled hypertension
  - History of breast cancer or venous thromboembolism (VTE)
  - Recent stroke, myocardial infarction or angina


# Types


HRT can be given systemically, either via oral tablets, transdermal patches or gels, or can be given vaginally for urogenital atrophy, in the form of tablets, creams, pessaries or vaginal rings. Transdermal is the preferred route if the woman is at risk of VTE.


Hormones that can be given as part of HRT are:


  - **Oestrogens:** oestradiol, estrone and conjugated oestrogen are generally used.
  - **Progestogens:** Medroxyprogesterone, norethisterone, levonorgestrel and drospirenone are typically used. A levonorgestrel-releasing intrauterine system (e.g. Mirena coil) may be used as part of the progestogen component of HRT, so the woman may just take oral oestrogen and have endometrial protection via the intrauterine system
  - **Tibolone:** this is a synthetic compound containing oestrogen, progestogen and androgens.


All women require a combination of oestrogen and progesterone as part of their HRT, unless they have had a hysterectomy, in which case oestrogen-only is enough. This is due to risk of endometrial cancer if oestrogen is given alone. 

HRT can be given continuously (for postmenopausal women not having periods) or cyclically (for perimenopausal women still having some periods). Cyclical can include:

- Monthly: Oestrogen every day of the month + progesterone for the last 14 days 
- Every three months: Oestrogen every day for 3 months + progesterone for the last 14 days


# Side Effects


  - Oestrogen: breast tenderness, leg cramps, bloating, nausea, headaches
  - Progestogen: premenstrual syndrome-like symptoms, mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain
  - Cholestatic jaundice
  - Increased risk of breast cancer, endometrial cancer, VTE, stroke and ischaemic heart disease

  
# NICE Guidelines

[CLick here for NICE guidelines on HRT](https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt/)

# References


[Primary Care Women's Health Forum](https://pcwhf.co.uk/resources/hrt-types-doses-and-regimens/#)

[Hickey & Davison 2012, The BMJ](https://www.bmj.com/content/344/bmj.e763.long)

[NHS Website](https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/types-of-hormone-replacement-therapy-hrt/)
1003
2365
Hormone replacement therapy
Topic
26
Gynaecology
Condition
423
Menopause
UkmlaTopic
18
Obstetrics and gynaecology
10676
Cyclical combined hormone replacement therapy is recommended for menopausal women with irregular periods to alleviate symptoms and protect the endometrium.
Presentation
373
Menopausal problems
UkmlaTopic
18
Obstetrics and gynaecology
A 55-year-old woman attends her GP seeking advice over her menopausal symptoms, which started just under a year ago. She gets regular hot flushes, which make her work in retail very difficult, as well as irritability at home, which has started interfering with her relationship. She says she still has the occasional period once every 4 months. She is otherwise fit and well with no past medical or surgical history. She would like treatment to help her symptoms and does not want any intrauterine devices or systems.

Which treatment would be most appropriate for this patient?
a