Management with HRT

Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Side-effects

• nausea
• breast tenderness
• fluid retention and weight gain

Potential complications

• increased risk of breast cancer
  • increased by the addition of a progestogen
  • in the Women's Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer
  • the increased risk relates to the duration of use
  • the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT
• increased risk of endometrial cancer
  • oestrogen by itself should not be given as HRT to women with a womb
  • reduced by the addition of a progestogen but not eliminated completely
  • the BNF states that the additional risk is eliminated if a progestogen is given continuously
• increased risk of venous thromboembolism
  • increased by the addition of a progestogen
  • transdermal HRT does not appear to increase the risk of VTE
  • NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal)
• increased risk of stroke
• increased risk of ischaemic heart disease if taken more than 10 years after menopause

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.