QuestionSBA
QuestionChoice
This patient can be prescribed oestrogen without progesterone ('unopposed oestrogen') as she has had a hysterectomy. Unopposed oestrogen causes hyperplasia of the endometrium, increasing the risk of endometrial cancer. Oestrogen can be prescribed as a tablet or a transdermal patch.
First line treatment would be oral oestrogen.
62418
a
Oral oestrogen
QuestionChoice
Whilst this could be offered to help with the symptoms of anxiety, the patient also presents with hot flushes.
A trial of HRT would be the first step, referral for CBT could be offered concurrently.
62422
e
Refer for cognitive behavioural therapy (CBT)
QuestionChoice
As this patient has had a hysterectomy she does not require progesterone alongside the oestrogen. Preparations of combined HRT are required when the patient has a uterus. This is because oestrogen on its own (unopposed) causes hypertrophy of the endometrium, leading to a risk of endometrial cancer.
62419
b
Combined oral HRT
QuestionChoice
FSH levels are not required to diagnose menopause in patients over the age of 45.
Patients between the age of 40 and 45 with menstrual cycle changes can have their FSH levels checked to confirm menopause. Patients under the age of 40 with menopausal symptoms can have their FSH levels checked to diagnose premature ovarian failure.
62420
c
A blood test for FSH levels before commencing HRT
QuestionChoice
Gabapentin can be prescribed for hot flushes, however, this patient has presented with anxiety and lethargy as well. Therefore, an HRT option would be most suitable.
62421
d
Gabapentin
QuestionComment
Hang on a minute, surely patch which reduces VTE risk would be first line no?
24238
QuestionComment
I think that prescribing patch HRT is more for women with h/o VTE/DVT or have a high risk of having a clot later on

26639
User
subscriber
JAK Gland
QuestionComment
Patient might prefer not to have a patch if sensitive skin (eczema)? 
27853
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Epidermis Pudendal
QuestionComment
So I think transdermal delivery is preferable regardless of baseline VTE risk, but its more expensive than oral. In specialist services they tend to prescribe transdermal first-line but I think in a GP setting they are more guided by money sadly so oral would be first-line?
28592
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Inpatient Syndrome
User
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Relapse CT
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/)
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Hormone Replacement Therapy
Topic
60
General Practice
12545
A 52 year old female attends her GP surgery to discuss Her menopausal symptoms. Her last period was 18 months ago. She has been more anxious and lethargic as of recently with episodes of hot flushes.
Her past medical history include eczema and fibroids for which she has had a hysterectomy.

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