Hormone Replacement Councelling

Introduction
 Introduce yourself and confirm the patient’s name, age (Patient Demographics)
 Privacy: Insure patient’s Privacy
 Permission: Gain consent with explaining what you are going to do.

First ask a few questions "First, I need to ask a few questions about you to check HRT is appropriate for you" ...
 Age (menopause age is 45-55 years), GP, Preg.
 SOCRATES
 Discuss their symptoms (and their effect on quality of life)
o Vasomotor instability
 Are there any associated night sweats, nausea, or palpitations?
 Any difficulty falling and staying asleep?
 Any history of Migraine or a particularly excessive headache?
o Urogenital atrophy:
 Are you experiencing itching, vaginal dryness or painful sexual intercourse" dyspareunia?"
 Any history of recurrent UTI?
 Any history of vaginal bleeding or discharges, decreased libido?
 Have you been passing urine more frequently? Any discomfort when passing urine.
 Do you feel any leakage of urine when you cough or sneeze? (stress incontinence)
 Do you worry that you cannot get to the bathroom in time? (urgency)
 Mesntrual Hx:
o Confirm menopause if possible (since when was your last period?)
o PV (per vaginal) bleeding (Undiagnosed PV bleeding is a CI, = Contraindication)
 Still having periods: ask COMPONENTS of Menst. Hx (see menstruation history in gyne
guide)
 No longer having periods: last menstrual period, any post -menopausal/post -coital bleeding
 Currently breastfeeding/pregnant (this is a CI)
 Relevant past medical history and family history
o PE/stroke/MI/angina/ Venous thromboembolism (CI)
o Estrogen dependent cancer (if currentlyCI) (breast/ endometrial/other), (Hx of breast cancer is CI)
o Do they have a uterus (i.e. no previous hysterectomy)?
o Other Contraindications: current Uncontrolled HT or Acute liver disease
 Past Meds./ Allergies

What they know already

 Their condition?
 What’s Menapause:
o Explain what the menopause is
 The time when periods cease, and a woman is no longer able to get pregnant
 Occurs because ovaries cease to produce hormones (estrogen and progesterone)
 These hormones (mainly estrogen) regulate the female reproductive system but also have many
other effects on the body e.g. mood, libido
 Symptoms last for 4 years on average (but can be up to 12)

 Determine their knowledge of HRT “what do you know about HRT?”

 Find out if there is anything in particular they wanted to know
 Explain what you would like to do (discuss what HRT is, the risks and benefits, types of HRT and also talk
about contraception if appropriate)

What HRT is and why it is used

Explain how HRT treats the symptoms: HRT replaces estrogen ± progesterone
Indications: pts w/ menopausal Sx (hot flushes…)
Contraind: Hx of Breast Ca, CHD, VTE/ Stroke, liver disease, endometrial Ca.
Benefits of HRT
 Short-term benefits - relief of:
o Vasomotor symptoms
o Psychological symptoms (anxiety, low mood)
o Reduced libido
o Urogenital atrophy - use vaginal HRT with or without systemic HRT
 Long-term benefits
o Reduction in osteoporosis (and related fractures)
o Reduced risk of coronary artery disease (<65 years)
Discuss risks and side effects
Discuss risks
 Venous thromboembolism (no risk with transdermal therapy)
 Stroke
 Breast cancer (small increase in risk with combined HRT only) Ovarian cancer (if used >5 years)
 Risk of Gallbladder disease
 Endometrial cancer (only if women with uterus take estrogen-only HRT - this is why estrogen-only HRT is
only used for women with no uterus)
Discuss side effects
 Estrogen: fluid retention, dyspepsia, breast tenderness, leg cramps, nausea/bloating
 Progesterone: pre-menstrual syndrome (mood swings, tender breasts, food cravings, fatigue, irritability and depression)
 All types: Weight gain
 Bleeding: PV bleeding occurs towards end of progesterone phase of cyclical HRT
Discuss types of HRT
Routes of administration
 Systemic: oral; transdermal (patches or gels) - available in estrogen-only or combined preparations
 Vaginal (for urogenital atrophy): tablet, cream, pessary or vaginal ring
Types of systemic therapy (discuss only one of the following based on the patient’s case)
 No uterus  estrogen-only HRT (oral or transdermal)
 Uterus  Estrogen + Progesterone
o Peri-menopausal  Cyclical HRT
 Cyclical HRT = Estrogen every day, but estrogen and progesterone given together for
12-14 days to cause bleed at the end of every menstrual cycle ‘monthly’ if still having
regular periods or every 13 weeks ‘three-monthly’ if having irregular periods
o Post-menopausal (i.e. no periods for >1 year or been on cyclical HRT for >1year)  Continuous HRT
 Continuous combined estrogen and progesterone, no bleed
Briefly mention contraception
 Women are potentially fertile for 1 year after last menstrual period (or 2 years if <50 years)
 Explain HRT is not contraception
 Contraceptive options for women on HRT
o Progesterone only pill (in addition to HRT)
o Mirena coil (can be used as progesterone component of HRT)
Discuss alternatives
 Mood: cognitive behavioral therapy, anti-depressants
 Vasomotor symptoms: SSRIs, SNRIs and clonidine
 Vaginal dryness: lubricants/moisturizers
 Irregular periods: Mirena coil
 OSTEOPOROSIS: Calcium and vitamin D
Bisphosphonates
 When to stop?
o Not More than 5 years or Not beyond 60 years

Lifestyle
 Smoking cessation
 Eat sensibly and try to avoid excessive weight gain
 Regular physical activity
 Stay in cold atmosphere and wear cotton clothes.
Ending
 Summarize
 Let patient think about it and plan follow up
 Offer leaflets/website links

Background knowledge on HRT

Indications
 Treatment of menopausal symptoms (when benefit outweighs risk)
 Treatment of early menopause (until natural menopause age·· 51 years)
 Osteoporotic fracture prophylaxis in women <60 years (when non-estrogen containing t treatments
are unsuitable)
Contraindications (all were covered in the previous questions)
Current
 Undiagnosed PV bleeding
 Pregnancy/breastfeeding
 Estrogen dependent cancer
 Acute liver disease
 Uncontrolled hypertension
History
 History of breast cancer
 History of venous thromboembolism
 Recent stroke/MI/angina
Types of HRT
Duration of HRT
 No maximum duration - individualize to women's risk vs benefits
 Risk increases after 65 years