Starting HRT

Starting HRT

Consider HRT in the following patients:

• perimenopausal or recently postmenopausal symptomatic women in whom risk factors for cardiovascular and thromboembolic disease are low
• who are at high risk of fracture (if there are no contraindications) - fracture risk can be calculated using an online tool such as FRAX and the bone density with bone densitometry

Before starting HRT:

• the following should be taken into consideration
  • nature and severity of menopausal symptoms and their impact on function and quality of life
  • woman’s age and health status
  • woman’s wishes for treatment.
• discuss modifiable risk factors for cardiovascular disease e.g. - alcohol, smoking, diabetes and hypertension control
• consider whether there is concomitant anxiety and/or depression since it is difficult to distinguish somatic symptoms of menopause (palpitations and sleep disorder) from those of depression and anxiety
• risks and benefits should be discussed individually and written information should be given
• breast and cervical screening should be up to date and any abnormal vaginal bleeding should be investigated

NICE state:

• starting and stopping HRT
  • explain to women with a uterus that unscheduled vaginal bleeding is a common side effect of HRT within the first 3 months of treatment but should be reported at the 3-month review appointment, or promptly if it occurs after the first 3 months
  • offer women who are stopping HRT a choice of gradually reducing or immediately stopping treatment
    • explain to women that:
      • gradually reducing HRT may limit recurrence of symptoms in the short term gradually
      • reducing or immediately stopping HRT makes no difference to their symptoms in the longer term

HRT preparations may vary between countries and regions

• the dosage and type of HRT should be adjusted according to the symptoms and possible side effects. The lowest effective dose of HRT should be prescribed at the beginning and in cases of persisting troublesome vasomotor symptoms, consider gradually increasing the dose after four to six weeks
• contraception may be necessary in perimenopausal women
• although there are no clear consensus on whether oral or transdermal therapy is first line, women with risk factors for thromboembolic disease or if oral absorption is limited transdermal preparations may be the first choice
• oestrogen alone should be used in women after hysterectomy
• cyclic HRT or (in women under 50 years) low dose combined oral contraceptives should be used in perimenopausal women to minimise irregular bleeding
• continuous combined HRT or tibolone should be considered in women who are one to two years postmenopausal and wish to avoid bleeding

Refrence

1. NICE. Menopause: identification and management. NICE guideline NG23. Published November 2015, last updated November 2024