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Hormone replacement therapy (HRT) counselling often features in OSCEs and therefore it’s important to be familiar with HRT, including its benefits and risks. This article focuses on how to counsel patients who are considering HRT, including how best to structure the consultation.

Check out the hormone replacement therapy (HRT) mark scheme here.


Opening the consultation

  • Introduce yourself
  • Check the patient’s details (name/date of birth)
  • Check the patient’s understanding of HRT
  • Explore the reasons why the patient wants HRT

Patient’s ideas, concerns and expectations

It is important to explore the patient’s ideasconcerns and 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 a sensitive and honest manner.

It’s also important to clarify the patient’s expectations of HRT.


What is HRT?

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

  • “Hormone 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 the increased 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 ways depending on their preference.

  • There 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 menopause is when menstruation becomes irregular and eventually stops. This occurs when the number of ovarian follicles becomes depleted. This results in a fall of the hormones oestrogen and progesterone. ²

Then explain that HRT works by replacing these hormones.

  • “The menopause occurs when your ovaries stop producing eggs. As a result of menopause, there is reduced production of the hormones oestrogen and progesterone in your body. This can result in symptoms such as hot flushes, weakened bones, vaginal dryness and urinary symptoms. 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 in the following circumstances:

  • For the treatment of menopausal symptoms where the risk/benefit ratio is favourable, in fully informed women.
  • For women with early menopause until the age of natural menopause (around 51 years), even if they are asymptomatic.
  • For those 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.
  • Suitable for perimenopausal and postmenopausal women.

 

Three-monthly HRT

  • Oestrogen is taken daily and progestogen is given for 14 days every 13 weeks.
  • Suitable for perimenopausal and postmenopausal women.

 

Continuous combined HRT

  • Oestrogen and progesterone are taken daily without any breaks.
  • 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.

 


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 the pros and cons of HRT.

  • “If 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 ¹ 

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
  • “HRT 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.
  • “HRT can, in some cases, improve low mood symptoms that arise as a result of the menopause.”

 

Improvement of urogenital symptoms ²

  • Various studies have shown that HRT significantly improves vaginal dryness and sexual function.
  • 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.
  • “HRT 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
  • “HRT 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
  • “HRT 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 ²

  • Oestrogen: breast tenderness, leg cramps, bloating, nausea, headaches.
  • Progestogen: premenstrual syndrome-like symptoms, breast tenderness, backache, depression, 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.
  • “Side 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 the HRT so that the patient is aware and can make an informed decision.

 

Venous thromboembolism 10

  • 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).
  • These risks increase with age and with other risk factors, 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 given for those women with an increased risk of VTE.
  • “HRT 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) 10

  • HRT is associated with a small increased risk of ischaemic stroke (oral oestrogen-only or combined HRT).
  • There is no evidence that transdermal preparations are associated with an increased risk of stroke.
  • “Oral 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 11

  • Combined HRT increases the risk of breast cancer. However, the absolute risk is small at around one extra case of breast cancer per 1,000 women each year.
  • The risk of breast cancer returns to that of a non-user after stopping HRT.
  • There is no 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.
  • “Some research suggests that HRT may increase the risk of breast cancer. The overall risk when taking combined oral HRT is thought to be small, causing around one extra case of breast cancer in every 1000 women each year. 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 ²

  • Oestrogen-only HRT substantially increases the risk of endometrial cancer in women with a uterus.
  • 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 women. We can provide some other medication to help reduce this risk. There is no increased risk of endometrial cancer if you take combined HRT.”

 


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

  • Ask the patient if they have any further questions or concerns that haven’t been addressed.
  • Throughout the consultation you should check the patient’s understanding regular intervals, using phrases such as “Can you just repeat back to me what we’ve just discussed regarding…”.
  • It may also be useful to quickly summarise what you have spoken about and direct the patient to any websites or leaflets with further information.
  • Make it clear that it is entirely the patient’s choice and offer her time to think about the decision.
  • Thank the patient for her time.

References

  1. Willacy, H. (2018). Hormone Replacement Therapy. Patient. [online] Patient.info. Available at: https://patient.info/doctor/hormone-replacement-therapy-including-benefits-and-risks [Accessed 20 Mar. 2019].
  2. Willacy, H. (2018). Menopause and its management. Patient. [online] Patient.info. Available at: https://patient.info/doctor/menopause-and-its-management [Accessed 20 Mar. 2019].
  3. Menopause Matters. (2011) Menopause Matters HRT Guidelines. Guidelines UK. Available at: https://www.guidelines.co.uk/womens-health/menopause-matters-hrt-guideline/200150.article [Accessed 20 Mar. 2019].
  4. Hickey M, Elliott J, Davison SL; Hormone replacement therapy. BMJ. 2012 Feb 16344:e763. doi: 10.1136/bmj.e763.
  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.
  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.
  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.
  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.
  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.
  10. Menopause: diagnosis and management; NICE Guidelines (November 2015)
  11. Chlebowski RT, Anderson GL; Menopausal hormone therapy and breast cancer mortality: clinical implications. Ther Adv Drug Saf. 2015 Apr6(2):45-56. doi: 10.1177/2042098614568300.
  12. NICE Clinical Knowledge Summaries. Menopause. Revised March 2017. [LINK]

 

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