Prescribing basics

Hormone Replacement Therapy (HRT) Counselling – OSCE Guide

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This guide provides an overview of hormone replacement therapy (HRT) counselling in an OSCE setting, including the different forms of HRT available and the associated benefits and risks.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including yourΒ nameΒ andΒ role.

Confirm the patient’sΒ nameΒ andΒ date of birth.

Explain theΒ reason for the consultation.

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Ideas, concerns and expectations

It is important to explore the patient’sΒ ideas,Β concernsΒ andΒ expectations early in the consultation, as you may need to correct any misconceptions about HRT. When exploring concerns, it is important to do so in aΒ sensitiveΒ andΒ honest manner. It’s also important to clarify the patient’sΒ expectationsΒ of HRT.


Explore what the patient currentlyΒ understands about HRT:

  • β€œHave you heard of HRT?”
  • β€œWhat do you already know about HRT?”
  • β€œDo you know why people take HRT?”


Ask if the patient has anyΒ concerns about HRT:

  • β€œIs there anything that worries you about HRT?”


Explore the patient’s expectations of the consultation and HRT:

  • β€œWhat were you hoping we’d discuss today?”
  • “What were you hoping HRT might be able to do for you?”

What is HRT?

Ensuring to use patient-friendly language, explain that HRT is a treatment that is used to alleviate the symptoms of menopause.

β€œHormone replacement therapy, often referred to as HRT, is an effective treatment for menopause-related symptoms. HRT can also have a positive influence on other long-term health problems associated with the menopause, such as reducing the risk of osteoporosis, cardiovascular disease and stroke. The aim of HRT is to restore the low levels of hormones that occur as a result of menopause.”1

How is HRT taken?

Explain to the patient that HRT can be taken in several different ways depending on their preference.

β€œThere are many ways in which you can take HRT, with the most common way being tablets (oral HRT). Other forms of HRT include skin patches, gels and implants such as the Mirena coil. You can try different forms and find the ones that work best for you.”

How does HRT work?

It may be useful to first explain to the patient that the menopause is when a woman stops having periods and is no longer able to get pregnant naturally. Menopause occurs when the number of ovarian follicles becomes depleted, resulting in decreasing levels of the hormones oestrogen and progesterone. Then go on to explain that HRT works by replacing these hormones.2

β€œThe menopause occurs when your ovaries stop producing eggs. As a result of the menopause, there are reduced levels of the hormones oestrogen and progesterone in your body. This can result in symptoms such as hot flushes, weakened bones and vaginal dryness. HRT works by replacing these hormones to varying degrees with the hope of reducing the symptoms and health problems associated with menopause.”

Who can take HRT?

HRT is indicated for:

  • the treatment of menopausal symptoms where the risk/benefit ratio is favourable
  • women with early menopause until the age of natural menopause (around 51 years), even if they are asymptomatic
  • women under 60 years who are at risk of an osteoporotic fracture in whom non-oestrogen treatments are unsuitable

What types of HRT regimes are available? 12

Combined HRT

Combined HRT refers to the use of both oestrogen and a progestogen.

Combined HRT is recommended for women with a uterus.

Progestogens are added to HRT regimens to reduce the increased risk of endometrial hyperplasia and cancer which occurs with unopposed oestrogen. Therefore, women who have had a hysterectomy do not usually require the addition of a progestogen.

There are several different ways to take combined HRT (monthly cyclical regimes, three-monthly cyclical regimes, continuous combined regimens).

Monthly HRT

Oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days.

Monthly HRT is suitable for perimenopausal and postmenopausal women.

Three-monthly HRT

Oestrogen is taken daily and progestogen is given for 14 days every 13 weeks.

Three-monthly HRT is suitable for perimenopausal and postmenopausal women.

Continuous combined HRT

Oestrogen and progesterone are taken daily without any breaks.

Continuous combined HRT is suitable for postmenopausal women.

Oestrogen-only HRT

Oestrogen-only HRT refers to the use of unopposed oestrogen therapy (e.g. no additional progestogen).

Oestrogen-only HRT is recommended for women without a uterus (e.g. hysterectomy) as they do not require the endometrial protection provided by progestogens.Β 

Pros and cons of HRT

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by discussing theΒ prosΒ andΒ consΒ of HRT.

β€œIf it is okay with you, I’d like to tell you about the benefits and disadvantages of HRT, then hopefully you will have enough information to make a decision.”

Advantages of HRT

Reduction of vasomotor symptoms

Vasomotor symptoms are usually improved within four weeks of starting treatment and the maximal benefit is gained by three months.

There has been shown to be a significant mean reduction in the frequency of hot flushes (by around 18 a week) and in the severity of hot flushes (by 87% compared with placebo).4

β€œHRT is particularly effective at reducing the frequency of hot flushes. Research suggests the frequency of hot flushes can be reduced by up to 87% with HRT.” 

Improved mood

HRT can improve mood and also depressive symptoms.5

HRT should be considered to alleviate low mood that arises as a result of the menopause.

β€œHRT can, in some cases, improve low mood symptoms that arise as a result of the menopause.”

Improvement of urogenital symptoms

Various studies have shown that HRT significantly improves vaginal dryness and sexual function.4

HRT is effective in improving the symptoms related to vaginal atrophy.

HRT can also relieve the symptoms of urinary frequency, as it has a proliferative effect on the bladder and urethral epithelium.

β€œHRT can have a positive impact on symptoms such as vaginal dryness and improve overall sexual function. HRT can also improve urinary symptoms, such as increased frequency of passing urine.” 

Reduces the risk of developing osteoporosis

HRT rapidly normalises turnover and preserves bone mineral density at all skeletal sites, leading to a significant reduction in vertebral and non-vertebral fractures.6,7

β€œHRT can help prevent thinning of the bones and therefore help reduce the risk of fractures.”

Cardiovascular protection

Taking HRT can reduce the risk of cardiovascular disease.8

Taking HRT has been shown to reduce the incidence of coronary heart disease by around 50% if it is started within ten years of the menopause.9

β€œHRT can help reduce the risk of cardiovascular diseases, such as high blood pressure and heart attacks. The risk reduction varies depending on when you start HRT and what other risk factors you already have.”

Disadvantages of HRT

Side effects

Side effects of HRT include:

  • Oestrogen: breast tenderness, leg cramps, bloating, nausea and headaches.2
  • Progestogen: premenstrual syndrome-like symptoms, breast tenderness, backache, depression and pelvic pain.
  • Bleeding: monthly sequential preparations should produce regular, predictable and acceptable bleeds starting towards the end, or soon after, the progestogen phase. Breakthrough bleeding is common in the first 3-6 months of continuous combined and long-cycle HRT regimens.

β€œSide effects of HRT vary, depending on the type of HRT used. If the HRT contains oestrogen, you may experience breast tenderness, leg cramps, bloating, nausea and headaches. If the HRT contains progestogen you may experience breast tenderness, backache, low mood and pelvic pain. Breakthrough bleeding is common in the first 3-6 months with continuous combined HRT.” 1

Risks of HRT

It is important to explain the risks of taking HRT so that the patient is aware and can make an informed decision.

Venous thromboembolism

The type, dose and delivery system of both oestrogen and progestogen influence the risk of thromboembolic disease.

Oral HRT (combined oestrogen and progestogen, and oestrogen-only) increases the risk of VTE (two to three times increase in risk).10

These risks increase with age and when other risk factors are present, such as obesity, previous thromboembolic disease, smoking and immobility.

In healthy women aged under 60 years, the absolute risk of thromboembolic disease is low and mortality risks from VTE are low.

Transdermal HRT should be prescribed for those women with an increased risk of VTE.

β€œHRT increases the risk of developing blood clots in the legs and lungs. These conditions can be treated with blood-thinning medication, however, they are serious medical conditions that can be life-threatening. The exact amount that HRT increases this risk varies depending on your individual risk factors and what type of HRT you take. Oral HRT increases your risk of developing blood clots by two to three times, however, the overall risk is still low. HRT delivered through your skin carries less risk of blood clots, so that is something we will consider.”

Ischaemic stroke (not haemorrhagic)

HRT is associated with a small increased risk of ischaemic stroke (oral oestrogen-only or combined HRT).10

There is no evidence that transdermal preparations are associated with an increased risk of stroke.

β€œOral forms of HRT slightly increase the risk of developing a stroke. A stroke occurs when a blood clot blocks a blood vessel in the brain, preventing the supply of oxygen to the brain tissue. Strokes can sometimes be treated, but they often result in long term disability and can be potentially fatal. You don’t have any other risk factors for stroke, so even with a small increase in risk, you are still very unlikely to develop a stroke. HRT preparations that are delivered through the skin do not carry this increased risk of stroke.”

Breast cancer

Combined HRT increases the risk of breast cancer. However, the absolute risk is small.

For every 1000 women aged 50-59 in the general population, on average, 23 cases of breast cancer will be diagnosed over the next five years. There will be approximately four additional cases in women on combined HRT.11

The British Menopause Society has produced an infographic which explains the risks of breast cancer with combined HRT and contrasts this with other breast cancer risk factors (e.g. obesity).

The risk of breast cancer returns to that of a non-user after stopping HRT.

There is noΒ evidence of an increased risk of breast cancer in women on HRT under the age of 51 years compared with menstruating women of the same age.

β€œSome research suggests that HRT may increase the risk of breast cancer. The overall risk when taking combined oral HRT is thought to be small and is less than other risk factors such as being overweight (BMI>30). Once you stop taking HRT, your risk of breast cancer returns to that of someone who has never taken HRT. There is no evidence of an increased breast cancer risk in women on HRT under the age of 51 years.”

Endometrial cancer

Oestrogen-only HRT substantially increases the risk of endometrial cancer in women with a uterus.4

The use of cyclical progestogen for at least ten days per 28-day cycle lowers this risk. Switching to continuous combined HRT after one year removes the risk.

“Oestrogen-only HRT significantly increases the risk of developing cancer in the lining of the womb. We can provide some other medication to help reduce this risk. There is no increased risk of endometrial cancer if you take combined HRT.”Β 

Contraindications to taking HRT 12

Contraindications to hormone replacement therapy (HRT) include:

  • Current, past, or suspected breast cancer
  • Known or suspected oestrogen-sensitive cancer
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
  • Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism), unless the woman is already on anticoagulant treatment
  • Active or recent arterial thromboembolic disease (for example angina or myocardial infarction)
  • Untreated hypertension
  • Active liver disease with abnormal liver function tests
  • Porphyria cutanea tarda
  • Pregnancy
  • Dubin-Johnson and Rotor syndromes (or monitor closely)

Closing the consultation

SummariseΒ theΒ keyΒ pointsΒ back to the patient.

Ask the patient if they have any further questionsΒ orΒ concernsΒ that haven’t been addressed.

Throughout the consultation you shouldΒ check the patient’s understandingΒ regularΒ intervals, using phrases such as β€œCan you just repeat back to me what we’ve just discussed regarding…”.

It may also be useful toΒ direct the patient to anyΒ websitesΒ orΒ leafletsΒ with further information.

Make it clear that it is entirely the patient’s choice and offer her time to think about the decision.

Thank theΒ patient for their time.

Dispose of PPE appropriately and wash your hands.


  1. Willacy, H. (2018).Β Hormone Replacement Therapy. Patient. [online] Available at: [LINK].
  2. Willacy, H. (2018).Β Menopause and its management. Patient. [online] Available at: [LINK] [Accessed 20 Mar. 2019].
  3. Menopause Matters. (2011) Menopause Matters HRT Guidelines. Guidelines UK. Available at: [LINK] [Accessed 20 Mar. 2019].
  4. Hickey M, Elliott J, Davison SL; Hormone replacement therapy. BMJ. 2012 Feb 16344:e763. doi: 10.1136/bmj.e763. Available at: [LINK].
  5. Studd J; Hormone therapy for reproductive depression in women. Post Reprod Health. 2014 Dec20(4):132-7. doi: 10.1177/2053369114557883. Epub 2014 Nov 14. Available at: [LINK].
  6. Gambacciani M, Levancini M; Hormone replacement therapy and the prevention of postmenopausal osteoporosis. Prz Menopauzalny. 2014 Sep13(4):213-20. doi: 10.5114/pm.2014.44996. Epub 2014 Sep 9. Available at: [LINK].
  7. Cauley JA; Estrogen and bone health in men and women. Steroids. 2015 Jul99(Pt A):11-5. doi: 10.1016/j.steroids.2014.12.010. Epub 2014 Dec 30. Available at: [LINK].
  8. Schierbeck L; Primary prevention of cardiovascular disease with hormone replacement therapy. Climacteric. 201518(4):492-7. doi: 10.3109/13697137.2015.1034098. Epub 2015 Apr 16. Available at: [LINK].
  9. Schierbeck LL, Rejnmark L, Tofteng CL, et al; Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ. 2012 Oct 9345:e6409. doi: 10.1136/bmj.e6409. Available at: [LINK].
  10. Menopause: diagnosis and management; NICE Guidelines (November 2015). Available at: [LINK].
  11. British Menopause Society. Understanding the risks of breast cancer. Available from: [LINK].
  12. NICE Clinical Knowledge Summaries. Menopause. Revised March 2017. Available at: [LINK].


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