Index

NICE CKS Menopause - Hormone replacement therapy (HRT). Last revised: Nov 2024.

Prescription Information

Breast cancer (current / past / suspected)
Oestrogen-dependent cancer (known / suspected)
Due to risk of endometrial cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
Due to risk of thromboembolism
- Active or recent arterial thromboembolism (e.g. angina, MI)
- Previous idiopathic or current DVT / PE (unless already on anticoagulant)
- Known thrombophilia disorder
Pregnancy
Active liver disease with abnormal LFTs

There are a few aspects to consider while choosing the HRT.

There 2 main routes: oral or transdermal (gel / patch / spray)

Indications for transdermal HRT (over oral HRT):

History / increased risk of venous thromboembolism (DVT / PE)
Presence of cardiovascular risk factors (e.g. obesity, uncontrolled hypertension, hypertriglyceridemia)
Concomitant hepatic enzyme-inducing drug treatment

Factors associated with inappropriate oral HRT
- Troublesome adverse effects with oral treatment
- GI disorder that may affect the absorption of oral treatment
- Lactose sensitivity (most oral preparations contain lactose)
- History of migraine / gallbladder disease

Choice depends whether patient has a uterus:

Choice of oestrogen:

'Natural' oestrogens preferred (e.g. conjugated oestrogen, oestradiol, oestrone, oestriol)
'Synthetic' oestrogens are generally not used (e.g. mestranol, ethinyloestradiol)

Choice of progestogen:

Synthetic progestogens are most commonly used (e.g. dydrogesterone, medroxyprogesterone, norethisterone, levonorgestrel, norgestrel, and drospirenone)

The choice of HRT regimen depends mainly on menopausal status:

Postmenopausal → continuous HRT regimen maybe preferred
- As there is no withdrawal bleeding
- But NICE CKS says both continuous and cyclical regimens maybe used

3 main categories of adverse effects associated with HRT:

Category	Description
Oestrogen-related	Fluid retention Bloating Breast tenderness / enlargement Nausea Headache Leg cramps Dyspepsia
Progesterone-related	Fluid retention Breast tenderness Headaches / migraine Mood swings Premenstrual syndrome-like symptoms Depression Acne vulgaris Lower abdominal / back pain
Vaginal bleeding problems	Monthly cyclical regimen → regular withdrawal bleeding (towards the end of the progesterone phase) Continuous regimen → irregular breakthrough bleeding or spotting in the first 4-6 months If bleeding persists beyond 6 months / becomes heavier / occurs after amenorrhea → exclude endometrial pathologies

NICE CKS Menopause: Hormone replacement therapy (HRT)

Author: Adams Lau
Reviewer:
Last edited: 26/04/25