Primary care HRT guidance

The younger the women at diagnosis the greater the risk of developing osteoporosis and increased morbidity

Confirmed low bone density should be actively treatment with a therapeutic estrogen replacement dose

Encourage Vitamin D, magnesium, Vitamin K supplements and weight bearing exercises 

Regular bone scans per guidance or as directed by the specialist

A serum estradiol of at least 250pmol/l is required to promote bone metabolism and reversal of bone loss – change estradiol dose and brand as required

A serum estradiol of at least 250pmol/l is required to promote bone metabolism and reversal of bone loss – change estradiol dose and brand as required

Refer to rheumatology if HRT is optimised but bone health not improving

Refer to menopause clinic if HRT is not optimised and bone health not improving

PMS/PMDD and the menopause present with a high incidence of suicide

Antidepressants are not recommended as first line treatment in the NICE guideline

Effective HRT will alleviate hormonal depression by replacing stable physiological hormone levels and serotonin equilibrium

 Co-morbid endogenous depression should be treated concurrently

Safety netting: Women with a history of suicidal risk or mental health disorders should have an up to date risk assessment and referral to mental health services 

Hormonal depression is best relieved with good stable estrogen replacement

The effective dose replacement is individual and the maximum licensed dose and alternative brands should be tried

High estrogen levels are often required, between 400-600pmol/l. Referral to secondary care may be indicated if off licence doses of estrogen is required

The development of progestogenic side effects often describe as PMS

A common limiting factor with the HRT, COCP, POP and IUS

There is usually at least 1 progestogen replacement that will be tolerated

Utrogestan is least likely to case side-effects and may be used off-label per vaginum to limit this effect

Contraception needs must be advised

Due to their synthetic nature, the COCP or POP are not usually effective, often worsening depressive symptoms

Due to their synthetic nature, the COCP or POP are not usually effective, often worsening depressive symptoms

Androgenic progestogens eg NET are more likely to provoke side effects and reduce adherence

Natural body-identical progesterone is least likely to precipitate side effects and can be used per vagina (off label)

The Mirena (licenced use) or  Kyleena (off label) are excellent options due to low systemic effects

The evidence does not support the use of transdermal compounded progesterone for the protection against endometrial hyperplasia or atypia in licensed HRT

See:

Hormonal depression and anxiety – in perimenopausal or postmenopausal women

Progesterone intolerance

Refer to the National Association of Premenstrual Syndrome guidelines (NAPS).

 A national support network for women with PMS/PMDD with evidence base treatment guidelines and patient support

Resistant PMS may require cycle suppression with GnRHa or ultimately surgery

Safety netting: Women with a history of suicidal risk or mental health disorders should have an up to date risk assessment and referral to mental health services 

A sequential combined HRT is only suitable for women who are perimenopausal or still having regular menstrual cycles

The licenced dose and duration of use should be adhered to when taking progestogen or progesterone

A lower dose or shorter duration significantly  increases the risk of irregular bleeding and potential for endometrial hyperplasia or atypia

Missing doses may be attributed to irregular bleeding but should still be investigated due to the risk undiagnosed pathology

All irregular bleeding should be investigated if continues beyond 4-6 months

A timed ultrasound scan after an induced bleed is advised

The endometrial result should about 5mm or less although there is no standard in menstruating women

Any abnormal pathology eg endometrial polyp, should be followed up according to your local care pathway

Changing to a more androgenic progestogen eg NET, or the Mirena is recommended

Any  persistent abnormal irregular bleeding, should be followed up according to your local care pathway

Where a specialist has recommended an un-licenced progesterone regimen twice yearly endometrial surveillance is indicted post withdrawal bleed

Unresolved symptoms often correlates with poor adherence or lack of effective absorption

This is one of the few occasions performing FSH/LH and serum estradiol have clinical value as other gynaecological disorders may present similarly

Symptoms generally resolved when serum estradiol >250pml/l. There is no upper limit but generally not >600pmol

If symptomatic on HRT use the full licensed dosing range, change brand or change route of administrations; with oral estradiol the last option (unless contraindicated)

Systemic HRT does not always resolve vaginal atrophic symptoms, but suboptimal replacement should be addressed

Local estrogen can be used to relieve symptoms whether or not systemic HRT is being used

HRT risks are not increased by using both systemic and local estrogen together

Any regular over the counter vaginal lubricants (for intimacy) and moisturiser (for daily rehydration) is advised in addition to or instead of local estrogen

A year of Vagifem 10mcg use is equivalent to one oral table of estrogen

Previous evidence based used of 25mcg Vagifem twice weekly is still extant. Therefore, Vagifem 10mcg can be used 4-5 times per week if symptoms persist

Where other vulval pathology is suspected a referral to dermatology vulval clinic is advised

Persistent recurrent UTI or vaginal infection to be referred to the respective specialist clinics

NICE guideline advise this is the only indication for using FSH/LH to aid diagnosis to aid exclusion of other gynaecological disorders that may present similarly

Discuss family planning, egg freezing, ovum donation, surrogacy, adoption

Offer contraception due to risk of sporadic ovulation or  unplanned pregnancy

Refer women under the age of 40 with POI to a specialist POI clinic, with baseline investigations, USS and BMD where possible

Early menopause may be treated as for all menopause women, but with greater consideration for effective estrogen replacement for long-term bone, heart and brain health and continued until at least the age of 51 or longer

POI Daisy network

A full health history should exclude any red flags prior to starting HRT

Unresolved symptoms may also indicate other comorbid diseases

Persistent unresolved symptoms may indicate other health disorders and should be excluded 

NICE CKS: What else might be causing symptoms