Clinical Symptoms That Warrant Hormone Replacement Therapy (HRT)
Hormone replacement therapy (HRT) is primarily indicated for the management of moderate to severe menopausal symptoms rather than for prevention of chronic conditions. 1
Primary Indications for HRT
Vasomotor Symptoms
- Moderate to severe hot flashes and night sweats are the most common indications for starting HRT 1, 2
- Hot flashes are characterized by recurrent, transient episodes of flushing, perspiration, and a sensation ranging from warmth to intense heat on the upper body and face, sometimes followed by chills 3
- Night sweats are hot flashes that occur with perspiration during sleep 3
- The severity of symptoms should be assessed based on their impact on quality of life and daily functioning 1
Genitourinary Symptoms
- Vaginal dryness, atrophy, and dyspareunia that significantly affect quality of life 1, 2
- Low-dose vaginal estrogen preparations can improve genitourinary symptom severity by 60-80% with minimal systemic absorption 1, 2
- Vaginal moisturizers and lubricants can be used as non-hormonal alternatives with a reduction in symptom severity of up to 50% 2
Premature Ovarian Insufficiency (POI)
- Women with premature ovarian insufficiency due to medical treatments like chemotherapy or radiation should be offered HRT at the time of diagnosis 1
- Most contraindications that apply to standard menopausal HRT do not apply with the same strength to women with POI, except in cases of hormone-sensitive cancers or history of thromboembolism 4
Special Considerations
Route of Administration
- Transdermal routes of HRT administration are preferred as they have less impact on coagulation factors 1, 4
- For women with hypertriglyceridemia, transdermal administration is recommended 5
- For women with an intact uterus, estrogen must be combined with progestogen to prevent endometrial hyperplasia and cancer 1, 4
Systemic Lupus Erythematosus (SLE) Patients
- HRT may be considered in SLE patients with negative antiphospholipid antibodies (aPL), stable low-level disease activity, severe vasomotor symptoms, and no other contraindications 3, 4
- HRT should be avoided in SLE patients with positive aPL antibodies or moderate to high disease activity 3, 4
Contraindications to HRT
Absolute Contraindications
- History of breast cancer 4, 6
- Coronary heart disease or history of myocardial infarction 4, 6
- Active liver disease 3, 4
- Antiphospholipid syndrome (APS) or positive antiphospholipid antibodies 3, 4
- Current or history of venous thromboembolism 6
- Unexplained vaginal bleeding 6
Relative Contraindications
- Women over 60 years or more than 10 years post-menopause have a less favorable risk-benefit profile 1, 4
- Hypertension (transdermal formulations preferred) 4
- History of gallbladder disease (increased risk with oral HRT) 3, 6
Important Clinical Considerations
Duration of Treatment
- Use the lowest effective dose for the shortest possible time needed to manage symptoms 1, 7
- Regular reassessment of the need for continued therapy is recommended 1
Risk-Benefit Assessment
- For every 10,000 women taking estrogen and progestin for 1 year, there might be 7 additional CHD events, 8 more strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers, balanced against 6 fewer cases of colorectal cancer and 5 fewer hip fractures 1
- Benefits include reduction in osteoporosis and fractures by approximately 30-50% 1, 2
- The absolute increase in risk from hormone therapy is modest in younger women (close to menopause) but should be carefully weighed against potential benefits for symptom relief 1, 8
Common Pitfalls to Avoid
- Initiating HRT solely for prevention of chronic conditions like osteoporosis or cardiovascular disease 3, 1
- Failing to distinguish between different HRT regimens and routes of administration, which can have varying risk profiles 1, 5
- Not considering transdermal estrogen for patients with risk factors for thromboembolism 4, 5
- Using HRT in women with obstetric and/or thrombotic APS 3