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HRT should be avoided in some clinical situations. But no one should be denied it based on outdated evidence or the personal opinion of the healthcare professional involved. Taking recent scientific data along with the most up-to-date information, I aim to clarify what information is needed to help make the decision about who can and can’t use HRT.

This article was included in issue 87 (winter 2020/21) of The Menopause Exchange newsletter.

To reach a joint decision, it’s all about informed consent: sit down with a healthcare professional and discuss the best way forward. They need to establish your individualised risk level. Is there anything that puts you at higher risk than another woman of your age seeking to relieve their menopausal symptoms?

Irregular vaginal bleeding without a diagnosed cause
The first thing a healthcare professional would like to know is whether anything about your gynaecological health is of concern. If your bleeding is over and you haven’t had a period for more than 12 months, you can be classed as postmenopausal. But if your bleeding has become irregular, we need to determine whether these are irregular periods or something else. Are you bleeding after sex, or between periods? Are you at risk of sexually transmitted disease? Are your cervical smears up to date?

It’s often tricky to identify what’s caused a change in bleeding, and it’s one of the most challenging aspects for healthcare professionals to know when to start HRT. Try using a menstruation tracking app to note your bleeding and your symptoms and tell your healthcare professional as best you can. If it feels like a period, then it probably is one.

Untreated thickening of your uterus (womb)
The health of your uterus (womb) is of vital importance. Endometrial hyperplasia (thickening of your uterus) can be a precursor (warning sign) of endometrial cancer. Depending on the type, you may be offered observation, treatment or a hysterectomy. While oestrogen-only HRT is associated with an increased risk of endometrial cancer, the addition of progestogen reduces this significantly.

Many women with endometrial hyperplasia that doesn’t need surgery will opt for an intrauterine device (IUS). This can provide a suitable progestogen component for HRT. So whether you’re waiting for the treatment to work or for surgery, your answer to HRT may be ‘not just yet’, rather than ‘never’.

A history of blood clots
If you have a higher risk of blood clotting (on your lungs or in your legs), it’s important to choose HRT carefully or, depending on the circumstances, avoid it altogether. Oral hormones can increase the risk of blood clotting.

Our blood gets stickier as we get older – especially after the age of 50 – and the risk increases with obesity. We need to evaluate what your risk level is, and whether you would want to increase that risk. If you’ve been diagnosed with, or have a family history of, a blood clotting disorder (thrombophilia) and are therefore more likely to have a blood clot, you’ll need specialist advice. HRT may not be out of the question altogether, and the choice of HRT can make all the difference: an appropriate oral HRT or HRT as a patch or gel with natural progesterone can limit your risk.

Active angina, after a recent heart attack and stroke risk
If you’ve recently had a heart attack or have angina, HRT wouldn’t usually be advised. But if you don’t fall into that category, strong evidence shows that HRT can protect your heart when given within 10 years of your last period.

If you start HRT after this, it may cause more harm than good – but again, it isn’t necessarily entirely ruled out. It all depends on your background risk, what else is going on in your life and how bad your menopausal symptoms are.

What about your stroke risk? As with blood clots (above), the general principle applies that transdermal HRT (across the skin) is thought to have a lower risk than oral oestrogens. But the medical evidence is limited. The key is modifying your background risk factors and choosing the treatment that’s right for you.

A history of breast cancer
HRT is usually avoided after breast cancer. But if you have tried nonhormonal methods or have exceptional circumstances, it’s sometimes considered. You need an individualised risk/benefit analysis with your oncology team and a menopause specialist so you can make a fully informed choice.

Do you have a genetic risk or a strong family history of breast cancer? If you have a gene mutation, you should seek further individual advice from your oncologist. If you’ve had risk-reducing surgery, emerging evidence suggests that using HRT afterwards doesn’t cancel out the risk reduction.

Oestrogen-dependent cancers
Oestrogen-dependent cancers include endometrial sarcoma and ovarian cancer. Endometrial sarcoma is oestrogen sensitive, and HRT isn’t recommended. For ovarian cancer, the evidence suggests that using oestrogen after ovarian cancer treatment may not worsen your long-term outcomes. But the type of ovarian cancer is vital to understanding when to avoid HRT. You’ll need the advice and full support of your oncologist.

HRT can be highly effective in easing menopausal symptoms. It has long-term health benefits too. But you need to know your individualised risks. For many, starting HRT isn’t a straightforward decision. It’s important to make a fully informed choice about what’s right for you by discussing this with a healthcare professional who understands the latest evidence on menopause management.

About the author
Dr Jane Davis is a GP from Cornwall and an advanced menopause practitioner and trainer. She’s a board member for PCWHF and holds the BMS/FSRH Advanced Certificate in Menopause Care.

Created Winter 2020

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