How to deal remotely with… HRT prescribing

Dr Kate Burns with the first article in a series on dealing remotely with common presentations, starting with HRT, including management of the menopause and monitoring

1) Possible menopause

Key pointers in the history

• Consider using an HRT history helper document to aid consultation (see pulsetoday.co.uk/HRT-helper1).

Ask reception staff to flag up anyone presenting about the menopause/HRT so you can consider its use. 

• Menopause is the permanent cessation of periods. It can only be diagnosed retrospectively once a woman has had no menstrual periods for 12 months in a row when not taking hormonal treatment.2,3

• Perimenopause is the time leading to the menopause. It can last months or years.3

• Does the patient have typical menopausal symptoms? Ask for her history and concerns, then check for common symptoms if needed. Hot flushes affect three-quarters of women.

• Does she have typical menstrual changes? There may be none. For other women, bleeds become infrequent, and either lighter or heavier or shorter or longer, then stop altogether. Check for red flags such as intermenstrual or postcoital bleeding, very heavy or prolonged bleeding, offensive discharge or postmenopausal bleeding (bleeding after 12 months of amenorrhoea).2

• Are there indicators of another cause for symptoms or systemic red flags? These might be night sweats with no other menopausal symptoms or menstrual changes, anorexia, unintentional weight loss or shortness of breath.

• Explore ideas, concerns and expectations. Does the patient have any specific worries? Is she hoping for tests?

Are investigations needed?

• Not unless there are indicators of another cause. FSH measurement is not required to diagnose perimenopause or menopause in women aged 45 or over, but is advised for women aged 40-44,

and essential for women under 40 with potential menopausal symptoms or menstrual changes. FSH can also help you decide whether a woman aged 50 or over needs to continue contraception.2

Further management and advice

The 3S approach is useful:

• Signpost to resources that offer symptom trackers and information on HRT and its alternatives.4,5,6,7

• Safety net Ensure the woman is aware of red flag symptoms such as bleeding anomalies.

• Support Advise her to contact you at any time for advice and support.

2) Starting HRT

Key pointers in the history

• Are there any contraindications to HRT or reasons to be cautious? Specifically ask about relevant history such as VTE, cardiovascular disease, migraine, breast or ovarian cancer, thyroid or liver/gallbladder disease.

• Is she sexually active? Consider her need for contraception. HRT is never contraceptive.8

• A computer template for HRT initiation and repeat prescribing may be useful.

Further management and advice

Either proceed with HRT prescription or signpost to further information and arrange follow-up. There is a lot of information to cover.

If starting HRT, the following three rules should help.9,10

1 Unless a woman has had a hysterectomy or has had a 52mg levonorgestrel intrauterine system in situ for less than five years, all women need both oestrogen and progestogen continuously or cyclically, as appropriate. There are two caveats: first, some women who have had a subtotal hysterectomy may still need progestogen (check with surgeon if unsure); and second, women with endometriosis who have had a total hysterectomy may still require the addition of progestogen, at least initially, to avoid causing a recurrence of symptoms (check with gynaecology).

2 If a woman has had bleeding in the past 12 months or is unsure if she is post- or perimenopausal (for example, because she is on hormonal contraception), start with cyclical combined HRT to avoid inducing irregular bleeding.

3 Evidence is growing for a default choice of transdermal oestrogen plus either the intrauterine system (IUS) or the micronised progestogen utrogestan if required, unless there is a reason to do otherwise.9,10 The natural bioidentical utrogestan is often better tolerated and has a lower risk of both breast cancer and VTE than alternative progestogens.

Potentially opting for transdermal oestrogen has the following advantages(10):

• It doesn’t increase VTE risk so it can potentially be used if the patient has previously had VTE and is first choice if there are risk factors such as a BMI >30.

• It is first choice if there is a pre-existing history of arterial disease and poses a lower stroke risk than oral oestrogen.

• It does not increase migraine event risk and is first line for known sufferers.

• There is flexibility to alter the dose.

• Absorption is more reliable. This is particularly beneficial if there is a known history of gastrointestinal or malabsorption disorders.

• It is preferable for patients with thyroid disorders as oral oestrogen may impair levothyroxine absorption.

• Oral oestrogen may further libido via increasing sex-hormone bonding globulin levels, giving a lower free androgen index. The transdermal route avoids this.9,10

3) Unscheduled bleeding with HRT

Advise women that irregular bleeding or spotting in the first four to six months is not a concern. However, they should urgently report heavy (rather than light) or prolonged bleeding, bleeding lasting longer than six months, or bleeding that starts after some time without bleeding.

Key pointers in the history4

• The HRT being used: type, regimen, length of use, compliance and any recent changes in type or dose.

• Bleeding duration, timeline (in relation to HRT use), pattern, heaviness, red flags.

• Background: how long was the patient without periods before she started HRT?

• Sexual history and STI risk.

• The chance she may be pregnant.

• Risk factors for endometrial cancer – nulliparity, obesity, diabetes, PCOS.

Is an examination or further investigation necessary?

Unscheduled bleeding in the first six months of HRT use is of less concern.

Refer urgently if:

• Unscheduled bleeding starts after six months’ HRT use or recurs after six months with no bleeding.9

• Unscheduled bleeding continues past six months despite modifying progestogen.

• Bleeding is persistent, prolonged, heavy or there are red flags such as pelvic pain, postcoital bleeding or offensive discharge.

It may be valid to refer directly, as the main concern is endometrial pathology, which you would not see on examination.

Further management and advice

If the above criteria are not met, the Primary Care Women’s Health Forum states unscheduled bleeding on HRT should initially be managed by remote consultation.10 It advises endometrial cancer risk is lower with combined HRT than without HRT, especially if there was no bleeding before HRT initiation.5

If no referral is needed, modifying progestogen intake will control bleeding in most cases, especially if HRT has been recently started or changed. For continuous combined regimens, try increasing the dose of progestogen, and

if bleeding continues, change to a cyclical regimen. For sequential/cyclical regimens, try increasing the progestogen dose or increasing the duration of progestogen use: ie, from 12-14 days to up to 21 days per 28-day cycle.

The IUS no longer provides the progestogenic component of HRT if it has been in place longer than five years. However, don’t rush to remove it if contraception is required as the FSRH supports it remaining effective for up to seven years, or, if inserted over age 45, until age 55. You can add oral progestogen for endometrial protection.4

4) HRT side-effects10

Key pointers in the history

• What are the symptoms?

• What is the timeline in relation to HRT? Any recent changes in type or dose?

• Is there a pattern to the symptoms: are they constant or intermittent? Cyclical?

• Main oestrogenic side-effects: bloating, breast tenderness or swelling, nausea, leg cramps, headaches and indigestion.

• Main progestogenic side-effects: breast tenderness, swelling in other parts of the body, headaches or migraines, mood swings, depression, acne and GI issues.

Further management

Potential solutions if oestrogenic side-effects are suspected:

• Oral oestrogen: change to transdermal.

• Transdermal oestrogen: adjust dose.

Potential solutions if progestogenic side-effects are suspected:

• Swap oral combined HRT to a dydrogesterone preparation (if the woman wishes to continue oral HRT) or switch to transdermal oestradiol only with a different oral progesterone.

Progestogen is generally used in the last 12-14 days of the cycle. If those are the days of the side-effects, the first tactic should be to change the progestogen.

Dr Kate Burns is a GP in Bridgend, South Wales and works for Health & Her