Hormone Replacement Therapy (HRT)

Contraindications & Precautions

• Absolute contraindications include history of breast cancer, active or recent arterial thromboembolic disease (eg stroke or myocardial infarction), undiagnosed vaginal bleeding that requires investigation, severe liver disease and a history of venous thromboembolism

• Relative contraindications include uncontrolled hypertension that must be controlled prior to initiating HRT and migraine with aura due to a higher stroke risk

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Side Effects

• Common side effects include breast tenderness, nausea, headaches, bloating, leg cramps, skin irritation, mood swings, acne and lower libido

• Serious side effects involve an increased risk of venous thromboembolism, stroke, gallbladder disease and breast cancer with long-term use

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Risk–Benefit Profile

• Prolonged use of combined oral HRT in postmenopausal women with an intact uterus is associated with a modest increase in the risks of breast cancer, coronary heart disease, stroke and pulmonary embolism when used for more than five years

• Extended HRT use may confer a reduced risk of colorectal cancer and fractures, although overall mortality is not increased with use for less than five years

• The risk profile varies according to the type of HRT, duration of use and individual patient risk factors

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Administration & Route

• Transdermal HRT formulations (patches, gels or sprays) are associated with a lower risk of venous thromboembolism compared with oral formulations

• Oestrogen-only HRT in women who have undergone hysterectomy has a different risk profile compared with combined HRT

• Individualised dosing and route selection is essential based on patient comorbidities and preferences

Monitoring & Patient Evaluation

• A full medical workup, including a mammogram and Pap smear, is recommended before commencing HRT

• Regular monitoring of blood pressure, liver function and symptomatology is essential during treatment

• Reassessment of the continued need for HRT is advised, particularly if treatment extends beyond five years, with an individualised risk–benefit discussion

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Notes

• Individualised risk–benefit discussions are essential prior to HRT initiation

• The risk of adverse events varies by HRT type, duration and route of administration

• HRT is recommended for symptomatic menopausal women with an intact uterus and is not indicated solely for the prevention of heart disease or osteoporosis

• Gradual dose reduction is recommended when discontinuing HRT to prevent rebound flushing and other withdrawal symptoms