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Menopause - Management
Prescribing HRT
How should I manage women who have had a hysterectomy with HRT?
- Offer lifestyle advice.
- Advise the woman about the risks and benefits of oestrogen-based hormone replacement therapy (HRT) and record in the notes.
- For urogenital symptoms (e.g. vaginal dryness, dyspareunia) offer low-dose vaginal oestrogen (cream, pessary, tablet, or ring) or systemic (oral or transdermal) oestrogen replacement therapy:
- Vaginal oestrogen may be preferred if the woman does not wish to take, or cannot tolerate systemic oestrogen.
- For vasomotor symptoms (e.g. hot flushes, night sweats), with or without urogenital symptoms, offer systemic (oral, or transdermal) unopposed oestrogen replacement therapy.
- Decreased libido: seek specialist advice if considering testosterone patches or implants.
In depth
Are there any specific issues I should consider in a woman who has had a subtotal hysterectomy?
- A remnant of endometrial tissue may be present in women who have had a subtotal hysterectomy (in which the main part of the uterus is removed but the cervix is retained).
- To test for the presence of endometrial tissue, prescribe a 3-month course of cyclical hormone replacement therapy (HRT):
- If withdrawal bleeding occurs, endometrial tissue is present, and combined HRT should be started.
- If the woman does not have withdrawal bleeding, endometrial tissue is unlikely to be present, and oestrogen-only HRT may be started.
In depth
What follow up is required?
- Review 3 months after starting hormone replacement therapy (HRT) and once each year thereafter.
- At 3-months:
- Check blood pressure, body weight, and assess the effectiveness of treatment; adjust HRT to achieve symptom control.
- Enquire about any adverse effects and manage appropriately.
- Once each year:
- Check blood pressure, effectiveness of treatment and adjust to achieve symptom control.
- Enquire about adverse effects and manage appropriately.
- Re-assess the need for continuing HRT.
- Discuss the risks and benefits of HRT. Explain that some of the risks (e.g. ovarian cancer) associated with oestrogen-only HRT increase with longer duration of HRT. The risk decreases after stopping HRT.
- Perform a breast examination if indicated by personal or family history.
- Encourage breast awareness and participation in the national breast screening programme as appropriate for their age.
In depth
When should I refer women who have started HRT?
- Refer to secondary care if there is multiple treatment failure (e.g. three or more regimens have been tried).
In depth
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