Ten Tips for Prescribing HRT Remotely

1. Most women do not need a face to face consultation for an HRT review

Women taking HRT should have an annual review which ideally should be face to face but can easily be done remotely. Check that cervical and breast screening are up to date (if relevant)1. If they have had their blood pressure undertaken in the past year, then there is less need for a face to face review. Many women now have home monitors, so it is reasonable to ask them if they have had their blood pressure taken in the past year. A prescription for one year’s supply of HRT should be given.

Note: Transdermal oestrogen with micronised progesterone (Utrogestan) can actually lower blood pressure2. Synthetic progestogens can have a negative effect on blood pressure3. NICE guidelines are clear that cardiovascular risk factors such as hypertension should be appropriately managed and raised blood pressure is not a contraindication to taking HRT4.

2. Use the balance app to assess symptoms

Download the balance app, take the symptom questionnaire and generate a personal Health Report© and take to your GP appointment. This is really useful to assess their symptoms and should ideally be done before each menopause consultation1.

3. Signpost women evidence-based information about their menopause and HRT

Women should be signposted to evidence-based and unbiased information about their menopause and its management. There is plenty of information on balance-menopause.com and also on the British Menopause Society website.

4. Women having periods can still be given HRT

Women experiencing menopausal symptoms who have a change in their nature or frequency of periods are perimenopausal. The perimenopause can last for several years, even a decade, before periods stop and they become menopausal. These women can still safely start HRT and the dose of oestrogen often needs to increase when their periods stop. Starting HRT during the perimenopause is often very effective at improving menopausal symptoms.

5. Knowing which type of HRT to prescribe can be easy

Transdermal oestrogen and micronised progesterone are safest

Oestrogen through the skin as a patch or gel is the safest way of having oestrogen and is body identical5,6. There is no risk of venous thromboembolism with this way and very few contra-indications7. There is a list of different HRT ingredients, brands and strengths available here. This also includes dose conversions. Micronised progesterone (Utrogestan) is a body identical progesterone and is better tolerated as well as having a lower risk of breast cancer compared to synthetic progestogens. This can be prescribed as 100mg each evening (continuous / bleed-free) or 200mg for two out of four weeks (cyclical / sequential).

Most women should be given continuous (bleed free) HRT

If a woman has not had a period for around a year, then continuous HRT can be prescribed initially. If a woman is taking sequential (cyclical) HRT then after around a year this can be changed to continuous HRT, regardless of her age. This should lead to her periods stopping. If women are taking body identical HRT then they should be given 100mg micronised progesterone (Utrogestan) each evening. If a woman has no bleeding with the continuous micronised progesterone then this can be considered a contraception.

Mirena coil can be used as an alternative progestogen

The Mirena coil can be used as the progestogen part of HRT for 5 years. If the patient has had a Mirena coil in for more than 5 years, then this can be kept in situ and she should be given progesterone too. The Mirena can be replaced (or removed) in the future.

6. Women can take HRT indefinitely (there is no maximum age for taking HRT)

The benefits of HRT outweigh the risks for the majority of women8. Taking HRT can lower future risk of heart disease, diabetes, dementia and osteoporosis9. Women can be reassured that they can continue to take it for ever so do not need to stop taking it at a certain age. Older women are usually given lower doses.

7. Young women often need HRT too

Around 1 in 100 women under 40 years in the UK have an early menopause and need HRT (or the combined oral contraceptive pill) to reduce their future risk of heart disease and osteoporosis4. Young women often need higher doses of oestrogen to improve symptoms. HRT should be recommended routinely to women who are menopausal aged < 45 years, even if they have no symptoms in view of the benefits for future health.

8. Ask about symptoms related to vaginal dryness

Symptoms such as pain, burning, itching, discomfort and also urinary symptoms can be very common and usually worsen with time. Around one in five women taking HRT also need vaginal oestrogen (as a pessary, cream, gel or ring). Vaginal DHEA is also now available. Non-hormonal vaginal moisturisers and lubricants can also be offered.

9. The majority of women who bleed when they are taking HRT do not have underlying pathology

Vaginal bleeding is a very common side effect of taking HRT. Bleeding usually settles within the first three to six months of starting HRT. Every time the dose of HRT is increased, or the type of HRT is changed, then bleeding can occur. Pathology is more likely in women who have heavy and prolonged bleeding and women who have bleeding beyond 6 months despite modifying their progestogen intake or where there is a concern about the clinical presentation or bleeding amount / pattern should be investigated appropriately10.

For the majority of women experiencing bleeding, changing their progestogen often controls bleeding. The dose of Utrogestan can increase to 200mg each evening (or 300mg for two out of four weeks if taking cyclically). An alternative progestogen such as medroxyprogesterone acetate (MPA) (5-10mg each day or 20mg cyclically) can often effectively reduce bleeding.

10. Prescribing testosterone remotely is still possible

Women who have reduced sexual desire despite taking HRT can be considered for testosterone4. Using testosterone often also leads to improvement in mood, energy, concentration and stamina. Younger women with POI and women who have had a surgical menopause often benefit from taking testosterone. Ideally women should have their baseline testosterone and sex hormone binding globulin (SHBG) levels undertaken before prescribing and then at least annually. However, blood tests can be delayed, and women should be advised to monitor for any side effects, such as hirsutism. Side effects from testosterone are very uncommon. A patient information leaflet about testosterone is available here.

References

1. Zöllner YF, Acquadro C, Schaefer M. Literature review of instruments to assess health-related quality of life during and after menopause. Qual Life Res. 2005 Mar;14(2):309-27.

2. Issa Z, Seely EW, Rahme M, El-Hajj Fuleihan G. Effects of hormone therapy on blood pressure. Menopause. 2015 Apr;22(4):456-68.

3. Stanczyk F, Hapgood J, Winer S, and Mishell D. Progestogens Used in Postmenopausal Hormone Therapy: Differences in Their Pharmacological Properties, Intracellular Actions, and Clinical Effects. Endocrine Reviews 34:171–208

4. NICE. Menopause: diagnosis and management. NICE Guideline [NG23]. 2015. Available at: www.nice.org.uk/guidance/NG23

5.  L’Hermite M. HRT optimization, using transdermal estradiol plus micronized progesterone, a safer HRT. Climacteric 2013; 16: 44-53.

6.  Newson L, Lass A.  Effectiveness of transdermal oestradiol and natural micronised progesterone for menopausal symptoms. BJGP 2018; 68: 499-500

7. Vinogradova Y, Coupland C, Hippisley-Cox J Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ 2019;364:k4810

8. Baber RJ, Panay N, Fenton A, Group IMSW. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016;19:109-50

9. Manson JE, Aragaki AK, Rossouw JE et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials. JAMA. 2017; 318(10):927-938

10. Lou YY, Kannappar J, Sathiyathasan S. Unscheduled bleeding on HRT – do we always need to investigate for endometrial pathology? Int J Reprod Contracept Obstet Gynecol. 2017;6:4174-4178

Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGP

Updated: April 2020