Obstetrics & Gynaecology/Hormone replacement therapy

Hormone replacement therapy (HRT)

also: HRT · oestrogen replacement · tibolone

Overview

Oestrogen to relieve menopausal symptoms; a progestogen is added if the uterus is present to protect the endometrium.

Mechanism

Systemic oestrogen replaces the post-menopausal deficit → relieves vasomotor and urogenital symptoms and preserves bone. Unopposed oestrogen drives endometrial hyperplasia/cancer, so a progestogen (cyclical or continuous) is mandatory if the uterus is intact (none needed after hysterectomy).

Indications

Vasomotor symptoms (flushes/sweats)
Urogenital atrophy (topical oestrogen)
Premature ovarian insufficiency (until ~51)
Osteoporosis prevention (second-line)

The agents

Oestrogen-onlyoral or transdermal

ONLY if no uterus (hysterectomy).

Combined (oestrogen + progestogen)sequential or continuous

Uterus present; continuous combined once postmenopausal.

Transdermal oestrogen (patch/gel)

No increase in VTE risk — preferred if VTE/clot risk, migraine, or hepatic concern.

Tibolonesynthetic steroid

Oestrogenic + progestogenic + androgenic; continuous combined alternative.

Adverse effects

VTEserious

ORAL oestrogen only — transdermal does not raise VTE risk.

Breast cancerserious

Combined HRT, duration-related; minimal with oestrogen-only.

Strokeserious

Oral oestrogen; small absolute risk.

Breast tenderness, bleeding, bloatingcommon

Cautions & contraindications

Current / past breast cancerall

Oestrogen-sensitive cancer, undiagnosed vaginal bleedingall

Active VTE / thrombophilia (oral)all

Use transdermal if HRT essential.

Active liver diseaseall

Interactions

Enzyme inducers reduce oral oestrogen levels

Monitoring & kinetics

BP, breast awareness/mammography per programme,Review benefit/risk annually; investigate unscheduled bleeding

Oral vs transdermal route is the key safety decision (VTE/stroke). Topical vaginal oestrogen for isolated urogenital symptoms.

Source: NICE NG23 — Menopause · BNF — Sex hormones