HRT - Initial Consultation

It is very important to explore a woman's fears and understanding of the menopause and her expectations of using hormone replacement therapy.
Recent research and publicity has highlighted the risks as well as the benefits of hormone replacement therapy.¹ Therefore a thorough discussion, supported by written information, is essential for the woman to make informed decisions. There are separate articles that cover hormone replacement therapy in general and follow up assessments for women using hormone replacement therapy.

History

• Hysterectomy: cyclical progestogen must be added for those women with an intact uterus to prevent endometrial cancer.
• Bleeding: investigate any abnormal bleeding pattern before starting HRT.
• Explore risk factors for osteoporosis, breast cancer and coronary heart disease.
• Contraception: HRT does not provide contraception. See separate article on Contraception for the mature woman.
• Health promotion²: smoking, alcohol,³ diet, exercise, check cervical smear is up to date, discuss breast self examination, breast cancer screening.

Examination

• Blood pressure
• Height and weight
• Other examination, indicated by the history.

Investigations

• FSH: a high level can be used to confirm menopause, but is often normal in the peri-menopause.
• Thrombophilia screen if indicated in history or family history.

Further investigation of bone density, cardiovascular risk factors and abnormal bleeding pattern as indicated by the history and examination.

Indications

Relief of menopausal symptoms (short-term).
Prevention and treatment of cardiovascular disease and osteoporosis where there is premature menopause (long-term).⁴

Alternatives

Other therapies for the prevention and treatment of osteoporosis:

• Clonidine; licensed for the treatment of menopausal flushing.⁵
• Phytoestrogens; mild oestrogenic activity and there is limited evidence that soy reduced some oestrogen deficiency symptoms, especially hot flushes.⁶ May increase risk of endometrial hyperplasia.⁷ Phytoestrogens may slow the rate of bone loss, but fracture risk reduction has not been demonstrated.⁸
• High doses of progestogens effectively reduce hot flushes.⁹ Long-term safety including effects on the breast is not yet known.
• SSRIs are moderately effective at relieving vasomotor symptoms with moderate efficacy and may be tried for short periods.¹⁰
• Recent reports suggest that gabapentin reduces hot flushes.
• Herbs: many herbs have been promoted for their benefit in the management of menopausal symptoms, e.g. black cohosh,¹¹ chaste tree, St John's Wort, evening primrose oil, dong quai, wild yam cream, ginseng, kava kava and red clover. There is currently no evidence to support any beneficial effect.

Contraindications

• Oestrogen: breast tenderness, leg cramps, bloating, nausea, headaches.
• Progestogen: premenstrual syndrome-like symptoms, breast tenderness, backache, depression, pelvic pain.

These are still controversial.

• Reduction in risk of Alzheimer type dementia^12,13
• Colonic cancer risk reduction^14,15
• Reduced risk of macular degeneration and cataract formation^16,17
• Improved dentition and skin healing

Discuss risks - See Risks of HRT

Because of the lack of the first-pass effect on the liver, the non-oral route of administration may be preferable in women with:

• Hypertriglyceridemia
• Liver disease
• Migraine headaches
• Increased risk of venous thrombosis2

The non-oral route may also be appropriate for women who also take liver-enzyme inducing drugs, e.g. anticonvulsants, those with reduced gastrointestinal absorption and those with a history of gallstones.
For women with symptoms of urogenital atrophy alone, low-dose vaginal oestrogen is recommended. Some women on systemic therapy continue to experience urogenital symptoms and, for them, additional vaginal therapy is recommended.