Where can I refer a patient who needs hormone replacement therapy (HRT)?

Referral Options for Hormone Replacement Therapy

Patients requiring hormone replacement therapy should be referred to an endocrinologist as the primary specialist, with additional referrals to gynecology for women with specific reproductive concerns. 1

Primary Referral Options

• Endocrinology consultation is the first-line referral for all patients requiring hormone replacement therapy, particularly for those with multiple endocrine abnormalities 1
• Gynecology referral is appropriate for women with reproductive concerns, menstrual irregularities, or those requiring estrogen/progesterone replacement 1
• For cancer survivors with premature ovarian insufficiency (POI), a multidisciplinary team approach including endocrinologists, gynecologists, and oncologists is recommended 1

Specific Clinical Scenarios

For Hypophysitis/Pituitary Disorders:

• Immediate endocrinology referral for all grades of hypophysitis or pituitary dysfunction 1
• Emergency department referral for severe symptoms (Grade 3-4) with adrenal crisis requiring IV stress-dose steroids 1

For Premature Ovarian Insufficiency:

• Referral to reproductive endocrinology for fertility evaluation and consultation on assisted reproduction options 1
• Consider referral for oocyte cryopreservation in younger patients who wish to preserve fertility 1

For Testosterone Replacement:

• Endocrinology referral for patients requiring testosterone therapy, with careful monitoring of potential adverse effects 2
• Caution is required as testosterone products carry risks including venous thromboembolism, myocardial infarction, and stroke 2

Pre-Referral Workup

• For suspected pituitary disorders: Evaluate ACTH (AM), cortisol (AM), TSH, free T4, and electrolytes 1
• For suspected ovarian insufficiency: FSH, estrogen levels in premenopausal females with fatigue, loss of libido, mood changes, or oligomenorrhea 1
• For males with hypogonadism: LH and testosterone levels 1
• Consider MRI brain with pituitary cuts for patients with multiple endocrine abnormalities or new severe headaches 1

Important Considerations

• Patients with adrenal insufficiency need education on stress dosing, emergency injections, and medical alert identification before leaving your care 1
• When multiple hormone deficiencies are present, corticosteroids must be started first before other hormone replacements to avoid precipitating adrenal crisis 1
• For women with an intact uterus requiring HRT, estrogen plus progestin is recommended rather than estrogen alone to prevent endometrial cancer 3
• Transdermal 17β-estradiol is preferred over oral formulations for women with cancer-related late effects due to its superior safety profile 1

Common Pitfalls to Avoid

• Initiating HRT solely for prevention of chronic conditions like osteoporosis or cardiovascular disease is not recommended as the risks may outweigh the benefits 1, 3
• Failing to consider contraindications such as hormone-sensitive cancers before referring for systemic hormone therapy 4, 3
• Not providing patient education about potential risks of HRT, including increased risk of venous thromboembolism, CHD, and stroke within the first 1-2 years of therapy 5, 3
• Overlooking the need for bone mineral density evaluation in hypogonadal patients 1