11/13/24, 8\:18 PM Guide | HRT counselling

HRT counselling

Table of contents

Introduction

This guide provides an overview of hormone replacement therapy (HRT) counselling in an OSCE setting, including the
di

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation.

Ideas, concerns & expectations

It is important to explore the patient’s ideas, concerns and expectations early in the consultation, as you may need to correct
any misconceptions about HRT. When exploring concerns, it is important to do so in a sensitive and honest manner. It’s also
important to clarify the patient’s expectations of HRT.

Ideas

Explore what the patient currently understands about HRT\:
“ H a v e y o u h e a r d o f H R T ?”
“ W h a t d o y o u a l r e a d y k n o w a b o u t H R T ?”
“ D o y o u k n o w w h y p e o p l e t a k e H R T ?”

Concerns

Ask if the patient has any concerns about HRT\:
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t H R T ?”

Expectations

Explore the patient's expectations of the consultation and HRT\:
“ W h a t w e r e y o u h o p i n g w e’ d d i s c u s s t o d a y ?”
" W h a t w e r e y o u h o p i n g H R T m i g h t b e a b l e t o d o f o r y o u ?"

What is HRT?

Ensuring to use patient-friendly language, explain that HRT is a treatment that is used to alleviate the symptoms of
menopause.
“ H o r m o n e r e p l a c e m e n t t h e r a p y , o f t e n r e f e r r e d t o a s H R T , i s a n e
a l s o h a v e a p o s i t i v e i n
o s t e o p o r o s i s , c a r d i o v a s c u l a r d i s e a s e a n d s t r o k e . T h e a i m o f H R T i s t o r e s t o r e t h e l o w l e v e l s o f h o r m o n e s t h a t o c c u r a s a r e s u l t
o f m e n o p a u s e .
”
1
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How is HRT taken?

Explain to the patient that HRT can be taken in several di
“T h e r e a r e m a n y w a y s i n w h i c h y o u c a n t a k e H R T , w i t h t h e m o s t c o m m o n w a y b e i n g t a b l e t s ( o r a l H R T ) . O t h e r f o r m s o f H R T
i n c l u d e s k i n p a t c h e s , g e l s a n d i m p l a n t s s u c h a s t h e M i r e n a c o i l . Y o u c a n t r y d i
”
y o u .

How does HRT work?

It may be useful to
to get pregnant naturally. Menopause occurs when the number of ovarian follicles becomes depleted, resulting in decreasing
levels of the hormones oestrogen and progesterone. Then go on to explain that HRT works by replacing these hormones.
2
“ T h e m e n o p a u s e o c c u r s w h e n y o u r o v a r i e s s t o p p r o d u c i n g e gg s . A s a r e s u l t o f t h e m e n o p a u s e , t h e r e a r e r e d u c e d l e v e l s o f t h e
h o r m o n e s o e s t r o g e n a n d p r o g e s t e r o n e i n y o u r b o d y . T h i s c a n r e s u l t i n s y m p t o m s s u c h a s h o t
v a g i n a l d r y n e s s . H R T w o r k s b y r e p l a c i n g t h e s e h o r m o n e s t o v a r y i n g d e gr e e s w i t h t h e h o p e o f r e d u c i n g t h e s y m p t o m s a n d
h e a l t h p r o b l e m s a s s o c i a t e d w i t h m e n o p a u s e .
”

Who can take HRT?

HRT is indicated for\:
the treatment of menopausal symptoms where the risk/bene
women with early menopause until the age of natural menopause (around 51 years), even if they are asymptomatic
women under 60 years who are at risk of an osteoporotic fracture in whom non-oestrogen treatments are unsuitable

Types of HRT

Combined HRT

Combined HRT refers to the use of both oestrogen and a progestogen.
Combined HRT is recommended for women with a uterus.
Progestogens are added to HRT regimens to reduce the increased risk of endometrial hyperplasia and cancer which occurs
with unopposed oestrogen. Therefore, women who have had a hysterectomy do not usually require the addition of a
progestogen.
There are several di
combined regimens).
Monthly HRT
Oestrogen is taken daily and progestogen is given at the end of the cycle for 10–14 days.
Monthly HRT is suitable for perimenopausal and postmenopausal women.
Three-monthly HRT
Oestrogen is taken daily and progestogen is given for 14 days every 13 weeks.
Three-monthly HRT is suitable for perimenopausal and postmenopausal women.
Continuous combined HRT
Oestrogen and progesterone are taken daily without any breaks.
Continuous combined HRT is suitable for postmenopausal women.

Oestrogen-only HRT

Oestrogen-only HRT refers to the use of unopposed oestrogen therapy (e.g. no additional progestogen).
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Oestrogen-only HRT is recommended for women without a uterus (e.g. hysterectomy) as they do not require the endometrial
protection provided by progestogens.

Pros and cons of HRT

Always give patients as much information as possible so that they can make an informed decision. It is useful to do this by
discussing the pros and cons of HRT.
“ I f i t i s o k a y w i t h y o u , I’ d l i k e t o t e l l y o u a b o u t t h e b e n e
”
t h e n h o p e f u l l y y o u w i l l h a v e e n o u gh

Advantages of HRT

Reduction of vasomotor symptoms
Vasomotor symptoms are usually improved within four weeks of starting treatment and the maximal bene
months.
There has been shown to be a signi
severity of hot
4
“ H R T i s p a r t i c u l a r l y e
”
R e s e a r c h s u gg e s t s t h e f r e q u e n c y o f h o t
Improved mood
HRT can improve mood and also depressive symptoms.
5
HRT should be considered to alleviate low mood that arises as a result of the menopause.
“ H R T c a n , i n s o m e c a s e s , i m p r o v e l o w m o o d s y m p t o m s t h a t a r i s e a s a r e s u l t o f t h e m e n o p a u s e .
”
Improvement of urogenital symptoms
Various studies have shown that HRT signi
4
HRT is e
HRT can also relieve the symptoms of urinary frequency, as it has a proliferative e
“ H R T c a n h a v e a p o s i t i v e i m p a c t o n s y m p t o m s s u c h a s v a gi n a l d r y n e s s a n d i m p r o v e o v e r a l l s e x u a l f u n c t i o n . i m p r o v e u r i n a r y s y m p t o m s , s u c h a s i n c r e a s e d f r e q u e n c y o f p a s s i n g u r i n e .
”
H R T c a n a l s o
Reduces the risk of developing osteoporosis
HRT rapidly normalises turnover and preserves bone mineral density at all skeletal sites, leading to a signi
vertebral and non-vertebral fractures.
6,7
“ H R T c a n h e l p p r e v e n t t h i n n i n g o f t h e b o n e s a n d t h e r e f o r e h e l p r e d u c e t h e r i s k o f f r a c t u r e s .
”
Cardiovascular protection
Taking HRT can reduce the risk of cardiovascular disease.
8
Taking HRT has been shown to reduce the incidence of coronary heart disease by around 50% if it is started within ten years of
the menopause.
9
“ H R T c a n h e l p r e d u c e t h e r i s k o f c a r d i o v a s c u l a r d i s e a s e s , s u c h a s h i gh b l o o d p r e s s u r e a n d h e a r t a t t a c k s . T h e r i s k r e d u c t i o n
v a r i e s d e p e n d i n g o n w h e n y o u s t a r t H R T a n d w h a t o t h e r r i s k f a c t o r s y o u a l r e a d y h a v e .
”

Disadvantages of HRT

Side e
Side e
Oestrogen\: breast tenderness, leg cramps, bloating, nausea and headaches.
2
Progestogen\: premenstrual syndrome-like symptoms, breast tenderness, backache, depression and pelvic pain.
Bleeding\: monthly sequential preparations should produce regular, predictable and acceptable bleeds starting towards the
end, or soon after, the progestogen phase. Breakthrough bleeding is common in the
combined and long-cycle HRT regimens.
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“ S i d e e
t e n d e r n e s s , l e g c r a m p s , b l o a t i n g , n a u s e a a n d h e a d a c h e s . I f t h e H R T c o n t a i n s p r o ge s t o ge n y o u m a y e x p e r i e n c e b r e a s t
t e n d e r n e s s , b a c k a c h e , l o w m o o d a n d p e l v i c p a i n . B r e a k t h r o u gh b l e e d i n g i s c o m m o n i n t h e
c o m b i n e d H R T .
”
1

Risks of HRT

It is important to explain the risks of taking HRT so that the patient is aware and can make an informed decision.
Venous thromboembolism
The type, dose and delivery system of both oestrogen and progestogen in
Oral HRT (combined oestrogen and progestogen, and oestrogen-only) increases the risk of VTE (two to three times increase in
risk).
10
These risks increase with age and when other risk factors are present, such as obesity, previous thromboembolic disease,
smoking and immobility.
In healthy women aged under 60 years, the absolute risk of thromboembolic disease is low and mortality risks from VTE are
low.
Transdermal HRT should be prescribed for those women with an increased risk of VTE.
“ H R T i n c r e a s e s t h e r i s k o f d e v e l o p i n g b l o o d c l o t s i n t h e l e g s a n d l u n g s . T h e s e c o n d i t i o n s c a n b e t r e a t e d w i t h b l o o d-t h i n n i n g
m e d i c a t i o n , h o w e v e r , t h e y a r e s e r i o u s m e d i c a l c o n d i t i o n s t h a t c a n b e l i f e-t h r e a t e n i n g. T h e e x a c t a m o u n t t h a t H R T i n c r e a s e s
t h i s r i s k v a r i e s d e p e n d i n g o n y o u r i n d i v i d u a l r i s k f a c t o r s a n d w h a t t y p e o f H R T y o u t a k e . O r a l H R T i n c r e a s e s y o u r r i s k o f
d e v e l o p i n g b l o o d c l o t s b y t w o t o t h r e e t i m e s , h o w e v e r , t h e o v e r a l l r i s k i s s t i l l l o w . H R T d e l i v e r e d t h r o u gh y o u r s k i n c a r r i e s l e s s
r i s k o f b l o o d c l o t s , s o t h a t i s s o m e t h i n g w e w i l l c o n s i d e r .
”
Ischaemic stroke (not haemorrhagic)
HRT is associated with a small increased risk of ischaemic stroke (oral oestrogen-only or combined HRT).
10
There is no evidence that transdermal preparations are associated with an increased risk of stroke.
“ O r a l f o r m s o f H R T s l i g h t l y i n c r e a s e t h e r i s k o f d e v e l o p i n g a s t r o k e . A s t r o k e o c c u r s w h e n a b l o o d c l o t b l o c k s a b l o o d v e s s e l i n
t h e b r a i n , p r e v e n t i n g t h e s u p p l y o f o x y g e n t o t h e b r a i n t i s s u e . S t r o k e s c a n s o m e t i m e s b e t r e a t e d , b u t t h e y o f t e n r e s u l t i n l o n g
t e r m d i s a b i l i t y a n d c a n b e p o t e n t i a l l y f a t a l . Y o u d o n' t h a v e a n y o t h e r r i s k f a c t o r s f o r s t r o k e , s o e v e n w i t h a s m a l l i n c r e a s e i n r i s k ,
y o u a r e s t i l l v e r y u n l i k e l y t o d e v e l o p a s t r o k e . H R T p r e p a r a t i o n s t h a t a r e d e l i v e r e d t h r o u gh t h e s k i n d o n o t c a r r y t h i s i n c r e a s e d
r i s k o f s t r o k e .
”
Breast cancer
Combined HRT increases the risk of breast cancer. However, the absolute risk is small.
For every 1000 women aged 50-59 in the general population, on average, 23 cases of breast cancer will be diagnosed over the
next
11
The British Menopause Society has produced an infographic which explains the risks of breast cancer with combined HRT and
contrasts this with other breast cancer risk factors (e.g. obesity).
The risk of breast cancer returns to that of a non-user after stopping HRT.
There is no evidence of an increased risk of breast cancer in women on HRT under the age of 51 years compared with
menstruating women of the same age.
“ S o m e r e s e a r c h s u g g e s t s t h a t H R T m a y i n c r e a s e t h e r i s k o f b r e a s t c a n c e r . T h e o v e r a l l r i s k w h e n t a k i n g c o m b i n e d o r a l H R T i s
t h o u g h t t o b e s m a l l a n d i s l e s s t h a n o t h e r r i s k f a c t o r s s u c h a s b e i n g o v e r w e i gh t ( B M I > 3 0 ) . O n c e y o u s t o p t a k i n g H R T , y o u r r i s k o f
b r e a s t c a n c e r r e t u r n s t o t h a t o f s o m e o n e w h o h a s n e v e r t a k e n H R T . T h e r e i s n o e v i d e n c e o f a n i n c r e a s e d b r e a s t c a n c e r r i s k i n
w o m e n o n H R T u n d e r t h e a g e o f 5 1 y e a r s .
”
Endometrial cancer
Oestrogen-only HRT substantially increases the risk of endometrial cancer in women with a uterus.
4
The use of cyclical progestogen for at least ten days per 28-day cycle lowers this risk. Switching to continuous combined HRT
after one year removes the risk.
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" O e s t r o g e n-o n l y H R T s i g n i
m e d i c a t i o n t o h e l p r e d u c e t h i s r i s k . T h e r e i s n o i n c r e a s e d r i s k o f e n d o m e t r i a l c a n c e r i f y o u t a k e c o m b i n e d H R T .
"

Contraindications to taking HRT

Contraindications to hormone replacement therapy (HRT) include\:
Current, past, or suspected breast cancer
Known or suspected oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism), unless the woman
is already on anticoagulant treatment
Active or recent arterial thromboembolic disease (for example angina or myocardial infarction)
Untreated hypertension
Active liver disease with abnormal liver function tests
Porphyria cutanea tarda
Pregnancy
Dubin-Johnson and Rotor syndromes (or monitor closely)

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any further questions or concerns that haven’t been addressed.
Throughout the consultation you should check the patient’s understanding regular intervals, using phrases such as “C a n y o u
j u s t r e p e a t b a c k t o m e w h a t w e’ v e j u s t d i s c u s s e d r e ga r d i n g…”
.
It may also be useful to direct the patient to any websites or lea
Make it clear that it is entirely the patient's choice and o
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. Willacy, H. (2018). Hormone Replacement Therapy. Patient. [online] Patient.info. Available at\: [LINK].
2. Willacy, H. (2018). Menopause and its management. Patient. [online] Patient.info. Available at\: [LINK] [Accessed 20 Mar. 2019].
3. Menopause Matters. (2011) Menopause Matters HRT Guidelines. Guidelines UK. Available at\: [LINK] [Accessed 20 Mar. 2019].
4. Hickey M, Elliott J, Davison SL; Hormone replacement therapy. BMJ. 2012 Feb 16344\:e763. doi\: 10.1136/bmj.e763. Available at\:
[LINK].
5. Studd J; Hormone therapy for reproductive depression in women. Post Reprod Health. 2014 Dec20(4)\:132-7. doi\:
10.1177/2053369114557883. Epub 2014 Nov 14. Available at\: [LINK].
6. Gambacciani M, Levancini M; Hormone replacement therapy and the prevention of postmenopausal osteoporosis. Prz
Menopauzalny. 2014 Sep13(4)\:213-20. doi\: 10.5114/pm.2014.44996. Epub 2014 Sep 9. Available at\: [LINK].
7. Cauley JA; Estrogen and bone health in men and women. Steroids. 2015 Jul99(Pt A)\:11-5. doi\: 10.1016/j.steroids.2014.12.010. Epub
2014 Dec 30. Available at\: [LINK].
8. Schierbeck L; Primary prevention of cardiovascular disease with hormone replacement therapy. Climacteric. 201518(4)\:492-7.
doi\: 10.3109/13697137.2015.1034098. Epub 2015 Apr 16. Available at\: [LINK].
9. Schierbeck LL, Rejnmark L, Tofteng CL, et al; E
postmenopausal women\: randomised trial. BMJ. 2012 Oct 9345\:e6409. doi\: 10.1136/bmj.e6409. Available at\: [LINK].
10. Menopause\: diagnosis and management; NICE Guidelines (November 2015). Available at\: [LINK].
https\://app.geekymedics.com/osce-guides/counselling/hrt-counselling/ 5/611/13/24, 8\:18 PM Guide | HRT counselling
11. British Menopause Society. Understanding the risks of breast cancer. Available from\: [LINK].
12. NICE Clinical Knowledge Summaries. Menopause. Revised March 2017. Available at\: [LINK].
Source\: geekymedics.com
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