What is the initial workup for women considering Hormone Replacement Therapy (HRT)?

Initial Workup for Women Considering Hormone Replacement Therapy (HRT)

The initial workup for women considering HRT should include a comprehensive risk assessment focusing on cardiovascular health, breast cancer risk, and reproductive history, along with baseline measurements of blood pressure and weight. 1

Core Components of Initial Evaluation

Medical History Assessment

• Obtain detailed menopause symptom history including severity and impact on quality of life 1, 2
• Document complete gynecological history including age of menopause onset, whether natural or induced 3
• Assess for premature ovarian insufficiency (POI) if menopause occurred before age 40 3
• Review personal and family history of cardiovascular disease, venous thromboembolism, and stroke 3, 2
• Document personal and family history of breast, endometrial, and ovarian cancer 3, 1
• Evaluate history of hypertension, which is not a contraindication but may influence route of administration 3
• Screen for history of migraine, which may require special consideration for HRT regimen 3
• Document history of endometriosis or other gynecological conditions 3

Physical Examination

• Measure blood pressure (should be monitored at least annually) 3
• Record weight and BMI (should be monitored annually) 3
• Perform breast examination 3
• Conduct pelvic examination to assess for genital atrophy 2

Laboratory Testing

• No routine laboratory monitoring is required before initiating HRT unless indicated by specific symptoms or concerns 3
• For women with Turner Syndrome or specific risk factors, consider lipid profile, fasting plasma glucose, and HbA1c 3

Risk-Benefit Assessment

Cardiovascular Risk Assessment

• Evaluate smoking status (should be monitored annually) 3
• Consider transdermal estradiol for women with hypertension 3
• Inform patients that HRT initiated early after menopause may have cardiovascular benefits 3, 2

Cancer Risk Assessment

• Women should be informed that HRT has not been found to increase breast cancer risk before the age of natural menopause in POI patients 3
• HRT is generally contraindicated in breast cancer survivors 3
• Women with BRCA1/2 mutations but without personal history of breast cancer may consider HRT after prophylactic oophorectomy 3

Bone Health Considerations

• Consider baseline bone density assessment, especially for women at high risk for osteoporosis 3
• Inform patients that HRT has a role in bone protection 3

HRT Selection Considerations

Route and Formulation

• 17-β estradiol is preferred to ethinylestradiol or conjugated equine estrogens 3
• Consider transdermal administration, especially for women with hypertension or increased thrombotic risk 3, 2
• For women with an intact uterus, progestogen must be given in combination with estrogen to protect the endometrium 3, 4
• Micronized natural progesterone may have advantages, though oral cyclical combined treatment has strongest evidence for endometrial protection 3

Special Populations

• For women with endometriosis who required oophorectomy, combined estrogen/progestogen therapy is recommended 3
• For women with POI, HRT should be continued until at least the average age of natural menopause 3
• For adolescents with POI, follow age-appropriate dosing schedules 3

Common Pitfalls to Avoid

• Initiating HRT solely for prevention of chronic conditions rather than symptom management 3, 1
• Failing to provide progestogen for women with an intact uterus, increasing endometrial cancer risk 4
• Not considering transdermal estrogen for women with hypertension or increased thrombotic risk 3, 2
• Overlooking the need for contraception in perimenopausal women 3
• Not discussing the modest but real risks of HRT, including potential for increased stroke, venous thromboembolism, and breast cancer with long-term use 3

Follow-up Recommendations

• Once established on therapy, women using HRT should have a clinical review annually 3
• Pay particular attention to compliance during follow-up visits 3
• No routine monitoring tests are required but may be prompted by specific symptoms or concerns 3
• For women considering androgen therapy, treatment effect should be evaluated after 3-6 months 3