What is the recommended assessment and treatment approach for peri-menopausal and menopausal women using Hormone Replacement Therapy (HRT) according to Canadian guidelines?

Evidence-Based HRT Template for Peri-Menopause and Menopause Assessment and Management

Hormone replacement therapy (HRT) should be offered to women experiencing moderate to severe menopausal symptoms, using the lowest effective dose for the shortest duration necessary, with regular reassessment every 3-6 months. 1

Initial Assessment

History

• Menopausal Status Assessment:

  • Age (median age of menopause: 51 years)
  • Menstrual pattern changes
  • Duration and severity of symptoms
  • Timing of last menstrual period

• Symptom Assessment:

  • Vasomotor symptoms (hot flashes, night sweats)
  • Genitourinary symptoms (vaginal dryness, dyspareunia)
  • Psychological symptoms (mood changes, sleep disturbances)
  • Musculoskeletal symptoms (joint pain)

• Risk Assessment:

  • Personal/family history of breast cancer
  • History of venous thromboembolism (VTE)
  • Cardiovascular disease risk factors
  • Liver disease
  • Unexplained vaginal bleeding
  • Smoking status
  • Osteoporosis risk factors

Physical Examination

• Blood pressure
• BMI
• Breast examination
• Pelvic examination
• Bone density assessment if indicated

Laboratory Testing

• FSH/estradiol levels (if diagnosis uncertain)
• Lipid profile
• Liver function tests
• Mammogram (if due)
• Pap smear (if due)

Treatment Recommendations

Indications for HRT

• Moderate to severe vasomotor symptoms
• Genitourinary symptoms not responding to local therapy
• Prevention of bone loss in high-risk women
• Premature menopause (<45 years)

Contraindications to HRT

• History of breast cancer
• Active or recent VTE
• Active liver disease
• Uncontrolled hypertension
• Current smokers >35 years
• Unexplained vaginal bleeding
• Endometrial cancer
• History of stroke or cardiovascular disease 1

HRT Regimens

For Women with Intact Uterus:

• Combined HRT (estrogen + progestin):
  • Conjugated equine estrogen 0.625 mg/day with medroxyprogesterone acetate 2.5 mg/day, OR
  • Transdermal estradiol 0.025-0.0375 mg/day patch with micronized progesterone 100 mg daily 1, 2
  • Estrogel 0.06% 0.75-1.5 mg/day (1-2 pumps) with micronized progesterone 100 mg daily 1

For Women without Uterus:

• Estrogen-only therapy:
  • Conjugated equine estrogen 0.625 mg/day, OR
  • Transdermal estradiol 0.025-0.0375 mg/day patch 1, 2
  • Estrogel 0.06% 0.75-1.5 mg/day (1-2 pumps) 1

For Vaginal Symptoms Only:

• Vaginal estrogen cream 2-4g daily for 1-2 weeks, then reduced to half the initial dose for a similar period
• Maintenance dose: 1g 1-3 times weekly 3

Special Populations

Perimenopausal Women:

• Combined oral contraceptives may be preferred if contraception is also needed
• HRT does not provide contraceptive protection 1

Premature Ovarian Insufficiency (<45 years):

• HRT recommended until at least the average age of natural menopause
• Higher doses may be required 1

Women with History of Endometriosis:

• Combined estrogen/progestogen therapy to reduce risk of disease reactivation 1

BRCA1/2 Mutation Carriers:

• HRT is an option after prophylactic bilateral salpingo-oophorectomy without personal history of breast cancer 1

Non-Hormonal Alternatives

For women with contraindications to HRT:

• SSRIs/SNRIs (e.g., paroxetine 10-12.5mg, venlafaxine)
• Gabapentin
• Vaginal moisturizers and lubricants for local symptoms 1

Monitoring and Follow-up

• Initial follow-up at 3 months to assess symptom control and side effects
• Regular follow-up every 3-6 months
• Annual gynecological assessment
• Immediate evaluation of any vaginal bleeding
• Bone density monitoring if indicated
• Attempt to taper/discontinue HRT every 3-6 months 1, 2

Patient Education

• Benefits and risks of HRT (including increased risk of breast cancer, stroke, VTE with long-term use)
• Importance of regular follow-up
• Signs/symptoms requiring immediate medical attention
• Lifestyle modifications (exercise, smoking cessation, calcium/vitamin D intake)
• HRT is not contraceptive for perimenopausal women 1

Risk-Benefit Discussion

Patients should be informed that for 10,000 women taking estrogen and progestin for 1 year:

• 7 additional CHD events
• 8 more strokes
• 8 more pulmonary emboli
• 8 more invasive breast cancers
• 6 fewer cases of colorectal cancer
• 5 fewer hip fractures 1

This template provides a comprehensive, evidence-based approach to HRT assessment and management for Canadian healthcare providers treating women in peri-menopause and menopause, with emphasis on individualized care and regular reassessment.