QuestionSBA
QuestionChoice
Vaginal dryness is a common symptom of menopause. HRT should help to prevent vaginal dryness. Topical preparations of oestrogen can be used to treat vaginal dryness where only local symptoms are menopause are bothersome.
50124
d
HRT may cause vaginal dryness
QuestionChoice
Cyclical HRT is a combination of oestrogen and a progestogen where the progestogen is taken in the second half of a 28day cycle. Patients taking this regimen will have a regular withdrawal bleed. The progestogen causes the uterus lining to build up. This is then shed when the progestogen is stopped. It is important to note that this is not a period as HRT does not restore/maintain ovulation.
50123
c
HRT will stop your bleeding
QuestionChoice
Oral Progestogen should be taken later on in your cycle to induce a withdrawal bleed, this is usually from day 14-28.
50122
b
Oral progestogen should be taken in the first 10 days of your cycle
QuestionChoice
HRT is not a contraceptive and women under 40 should continue to use contraception until 2 years after their last period. Women over 50 should continue to use contraception for a year after their last period.
50121
a
You should continue to use contraception for 2 years after your last period
QuestionChoice
HRT patches should be applied below the waistline, usually on the buttock or lower abdomen.
50125
e
HRT transdermal patches should be applied above the waistline
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
3604
Hormone Replacement Therapy
Topic
76
Obstetrics and Gynaecology
10072
Case presentation: A 44-year-old woman attends the GP with mood swings, hot flushes and an irregular menstrual cycle. She is having a menstrual bleed for around 4 days every 30-35 days. 


**PH**
Asthma

**DH**
Beclometasone inhaler

Salbutamol inhaler

Combined Cyclical Hormone Replacement Therapy (HRT) in the form of transdermal oestrogen patches and an oral progestogen are offered to the patient.

Question: Select the most important information that should be provided for this patient.
a