Management with HRT

Contraindications:

• Current or past breast cancer
• Any oestrogen-sensitive cancer
• Undiagnosed vaginal bleeding
• Untreated endometrial hyperplasia

Roughly 10% of women will have some form of HRT to treat their menopausal symptoms. There is a current drive by NICE to increase this number as they have found that women were previously being undertreated due to worries about increased cancer risk. If the woman has a uterus then it is important not to give unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given.

If the woman does not have a uterus then oestrogen alone can be given either orally or in a transdermal patch.

The primary reason for adding a progestogen to HRT is to protect the endometrium from the proliferative effects of unopposed oestrogen, which increases the risk of endometrial cancer. In women without a uterus, there is no endometrium to protect, so progestogen is unnecessary. Furthermore, the addition of a progestogen increases the risk of breast cancer compared to oestrogen-only HRT. The Women's Health Initiative study demonstrated that combined HRT carries a higher breast cancer risk (relative risk 1.26 at 5 years) compared to oestrogen alone.

Women should be advised that the symptoms of menopause typically last for 2-5 years and that treatment with HRT brings certain risks:

• Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
• Stroke: slightly increased risk with oral oestrogen HRT.
• Coronary heart disease: combined HRT may be associated with a slight increase in risk.
• Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
• Ovarian cancer: increased risk with all HRT.

Management with non-HRT

Vasomotor symptoms

• fluoxetine, citalopram or venlafaxine

Vaginal dryness

• vaginal lubricant or moisturiser