QuestionSBA
QuestionChoice
Whilst the preparation of the HRT (containing both oestrogen and progesterone for patients with a uterus) is appropriate, patients who are post menopausal should be prescribed continuous rather than cyclical preparations.
This patient has been amenorrhoic for over 12 months.
62416
d
Combined cyclical oral HRT
QuestionChoice
Vaginal oestrogen gel can be prescribed to patients with a uterus without also prescribing progesterone as systemic absorption of the oestrogen is minimal.  As the systemic absorption is minimal, this route does not help with systemic symptoms such as the hot flushes experienced by this patient. Topical oestrogen helps locally with symptoms such as vaginal dryness.
62415
c
Vaginal oestrogen gel
QuestionChoice
Patients can be reffered for cognitive behaviour therapy (CBT) to help with the symptoms of low mood and stress associated with menopause.
However, it would also be appropriate to offer hormonal HRT to this patient to help with the symptoms she has presented with hot flushes, lethargy and loss of libido.
62417
e
Referral for cognitive behaviour therapy
QuestionChoice
Transdermal oestrogen patches can be prescribed for those who have had troublesome side effects with oral HRT.
The oestrogen patch is only suitable for those without a uterus. Oestrogen without progesterone ('unopposed oestrogen) causes hyperplasia of the endometrium, increasing the risk of endometrial cancer. If the patient has a intrauterine system with progesterone in situ then an oestrogen only HRT can be prescribed.
62414
b
Oestrogen patch
QuestionChoice
Combined HRT contains both oestrogen and progesterone. Oestrogen cannot be given on its own if the person still has a uterus. Oestrogen without progesterone ('unopposed oestrogen') causes hyperplasia of the endometrium, increasing the risk of endometrial cancer.
A continuous regimen is usually preferred for patients who are postmenopausal, whereas a cyclical regimen is preferred in perimenopausal patients. Perimenopausal is when symptoms of the menopause emerge with irregular menstruation, menopause is defined by the absence of menstruation for 12 months.
62413
a
Combined continuous oral HRT
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
3507
Hormone Replacement Therapy
Topic
60
General Practice
12544
A 55 year old female attends her GP surgery to discuss her menopausal symptoms. Her last period was 18 months ago. She has noticed that she is having hot flushes, lethargy and loss of libido.

Her past medical history is of asthma.

Which of the following is the best next step in the management of this patient?
a