Is a family history of uterine cancer and current smoking status a contraindication (C/I) to starting hormone replacement therapy (HRT)?

Hormone Replacement Therapy with Family History of Uterine Cancer and Current Smoking Status

A family history of uterine cancer in a patient's mother is not a contraindication to starting hormone replacement therapy (HRT), but current smoking is a relative contraindication that requires using transdermal rather than oral HRT if treatment is necessary.

Family History of Uterine Cancer and HRT

• A family history of uterine cancer (such as in the patient's mother) is not a formal contraindication to starting HRT 1
• The risk/benefit profile of hormone therapy is favorable for most women without personal history of hormone-dependent cancers 1
• There is no evidence to contraindicate the use of systemic or topical hormone therapy for women with a family history of uterine cancer, as this differs from having the cancer personally 1

Smoking Status and HRT

• Current smoking is a relative contraindication to oral HRT but not to transdermal HRT 1, 2
• Smoking can reduce or completely cancel the efficacy of orally administered estrogens due to elevated hepatic clearance 2
• Smokers should only be treated via the transdermal route to avoid formation of unphysiological metabolites by bypassing the liver 2
• Non-hormonal therapy may be considered in patients who are deemed poor candidates for hormone replacement therapy, including smokers 1

Decision Algorithm for HRT in This Patient

1. If patient currently smokes:

   • Recommend smoking cessation as part of risk minimization 1, 2
   • If HRT is necessary for severe menopausal symptoms, use only transdermal estrogen preparations 2
   • Use the lowest effective dose for symptom control 1, 3

2. If patient has a family history of uterine cancer but no personal history:

   • HRT can be prescribed without specific contraindication 1
   • If the patient has an intact uterus, combined estrogen-progestin therapy must be used 1
   • If the patient has had a hysterectomy, estrogen-only therapy can be used 1

Important Considerations

• The risk of uterine cancer is primarily relevant for women with intact uteri using unopposed estrogen therapy 1
• Women with intact uteri must receive progestin along with estrogen to prevent endometrial hyperplasia 1
• For women who have had a hysterectomy, unopposed estrogen therapy is appropriate 1
• Smoking cessation should be strongly encouraged regardless of HRT decision 1, 2

Monitoring and Follow-up

• Regular clinical assessment is recommended for all women on HRT 4
• Bone density status should be assessed and monitored, especially in smokers who are at higher risk for osteoporosis 1
• The lowest effective dose should be used for the shortest duration needed to control symptoms 1, 3

Special Considerations

• If the patient has additional risk factors (such as personal history of breast cancer, history of multiple strokes), non-hormonal therapy should be considered 1
• Selective serotonin reuptake inhibitors or norepinephrine reuptake inhibitors can be used for vasomotor symptoms when HRT is contraindicated 1
• Non-pharmacological approaches such as cognitive-based therapy, yoga, and acupuncture can be considered as adjuncts 1