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Women with pre-existing medical problems are often denied HRT following adverse reports from the Million Women’s Study and Women’s Health Initiative published 15 years ago. This led to a 66% reduction in HRT use in the UK.

This article was included in issue 73 (summer 2017) of The Menopause Exchange newsletter.

Last year, NICE guidance clarified the role of HRT for women with menopausal symptoms but gave no guidance for women who have co-existing medical conditions. The benefits of HRT for this group often outweigh the risks, particularly in the protection against heart disease in younger women and the prevention of osteoporosis.

Deciding whether or not to prescribe HRT can be difficult, and healthcare professionals (HCPs) along with women, need to be given well informed, up-to-date information on a regular basis. Healthcare professionals should clarify the safety issues related to HRT and, where relevant, any drug interactions.

Any decisions in relation to women with an increased risk of heart disease, stroke and blood clots need careful thought and discussion with relevant healthcare professionals and menopause specialists.

Risk of heart disease
Heart disease occurs at a later age in women than in men and is more common after the menopause. The effect of HRT on heart disease depends on age and when it’s started after the menopause. Women in their 50s using HRT don’t have a significant risk of heart disease. If HRT is started within 10 years of the menopause, it has been shown to reduce the incidence of heart disease by over 40%. If however HRT is started (or restarted) in women over 60, this risk increases.

Women who are overweight, have high cholesterol or smoke may have a greater risk of heart disease. They will need to discuss risk factors and associated health problems before being prescribed HRT. Non-oral oestrogen HRT, such as patches and gels, prescribed at the lowest effective dose, are considered safest and may have some effect on lowering ‘bad’ cholesterol. There’s no clear evidence about using HRT in women after a heart attack.

Risk of stroke
In women under 60, the risk of stroke is very low but HRT tablets may increase this risk very slightly. Healthcare professionals prescribe the lowest dose of HRT that controls menopausal symptoms to minimise this risk. Non-oral HRT doesn’t increase the risk of stroke, so it may be recommended for women at risk of stroke. Unfortunately there’s no clear evidence or guidance about the use of HRT in a woman who has had a stroke.

High blood pressure
Research shows that HRT doesn’t affect blood pressure and that women who have controlled high blood pressure (hypertension) may take HRT. High blood pressure should be managed according to national guidance using anti-hypertensive medication. Once blood pressure is normalised, HRT can be prescribed.

Women with diabetes can use HRT. NICE guidance has confirmed that HRT doesn’t increase the chance of developing type 2 diabetes and is unlikely to be linked to poor blood sugar control. Diabetics are more likely to have high cholesterol and be at risk of high blood pressure, heart attacks and stroke.

Non-oral HRT may be a good choice for women with diabetes. If they still have a uterus, ‘body-identical’ progestogens, which include micronised progestogen and dydrogesterone, may also be a good choice as these have little effect on insulin sensitivity and cholesterol.

Prone to blood clots
Around one in 1000 of the UK population develops blood clots in their leg veins (deep venous thrombosis) and/or their lungs (pulmonary embolism). HRT tablets increase this risk along with age, obesity, immobility, inherited blood clotting disorders or having a first-degree relative who has had a blood clot.

The extra risk of blood clots with HRT tablets is greatest in the first year of use and increases with oestrogen dose. If a million women use HRT tablets, there will be two extra deaths from blood clots. This risk disappears if HRT has been stopped for five years or more. For women at risk of blood clots, a low dose, non-oral HRT (with micronised progesterone or dydrogesterone, if they have a uterus) may be offered because there’s little added risk with this HRT.

Some healthcare professionals may not prescribe HRT if a woman has a body mass index of more than 40 or if there’s a strong family history of blood clots.

Liver disease
HRT was originally thought to worsen liver function. Recently though, it was found to be safe in women with chronic liver disease, particularly primary biliary cirrhosis (PBC) and viral hepatitis. HRT may also improve bone health in patients with PBC and a high risk of osteoporosis. Non-oral HRT, which avoids liver metabolism, is usually recommended in these cases after specialist advice. Gallbladder disease is common in women, particularly after the menopause, but a small increased risk has been linked with HRT. Again non-oral HRT would be the best choice in high-risk women.

Women may suffer more fits during the perimenopause. Non-oral HRT is preferred, as some anti-epileptic medicines interact with HRT. Gabapentin (a medicine that treats epilepsy) can reduce the frequency and severity of hot flushes and is an alternative to HRT. The role of HRT in the prevention of osteoporosis is important for menopausal women with epilepsy. Some anti-epileptic medicines may reduce bone mineral density. Fits increase falls and potential fractures.

HRT can be prescribed for women with asthma. It helps bone protection in those taking steroid medication.

About the authors
Dr Katherine Gilmore is speciality registrar in community sexual and reproductive healthcare. Dr Diana Mansour is consultant in community gynaecology and reproductive healthcare. Both are in Newcastle upon Tyne.

Created Summer 2017

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