What important questions must be asked before prescribing hormone therapy (hormone replacement therapy, HRT) to a 54-year-old postmenopausal female presenting with symptoms of brain fog, hot flashes, and night sweats?

From the Guidelines

Before prescribing hormone therapy for this 54-year-old woman with menopausal symptoms, I would need to ask several important questions to ensure safety and appropriateness of treatment. I would inquire about her complete medical history, focusing on any history of breast cancer, endometrial cancer, ovarian cancer, or other hormone-sensitive cancers, as well as cardiovascular risk factors including history of stroke, heart attack, blood clots (deep vein thrombosis or pulmonary embolism), or known thrombophilia, as indicated by the 2024 guideline for the primary prevention of stroke 1. Liver disease history is important as it affects hormone metabolism. I would assess for undiagnosed vaginal bleeding, which requires evaluation before hormone therapy. Her family history of breast cancer or thrombotic disorders would be relevant. I would ask about her smoking status, as smoking increases cardiovascular risks with hormone therapy. Current medication use is essential to identify potential interactions. I would inquire about her specific symptom severity, impact on quality of life, and previous treatments attempted. Understanding her preferences, concerns, and expectations regarding hormone therapy would guide our shared decision-making. These questions are crucial because hormone therapy, while effective for menopausal symptoms, carries risks including increased chances of breast cancer, stroke, blood clots, and heart disease in certain populations, as discussed in the 2018 guideline on interventions to address sexual problems in people with cancer 1. Identifying contraindications and risk factors allows for appropriate patient selection and safer prescribing of hormone therapy. Some key points to consider include:

• History of breast cancer
• Liver disease
• History of myocardial infarction
• Known or suspected estrogen-dependent neoplasia
• History of deep vein thrombosis
• Thrombophilic disorders
• Family history of breast cancer or thrombotic disorders
• Smoking status
• Current medication use
• Specific symptom severity and impact on quality of life
• Previous treatments attempted
• Preferences, concerns, and expectations regarding hormone therapy. The most recent and highest quality study, the 2024 guideline for the primary prevention of stroke 1, provides the best evidence for guiding the decision to prescribe hormone therapy. This guideline emphasizes the importance of assessing for contraindications to menopausal hormone therapy use and considering alternative nonhormonal therapy if contraindications are present. It also highlights the need for shared decision-making and selection of menopausal hormone therapy preparation based on individual patient factors. By following this guideline and considering the patient's individual factors, we can ensure safer and more effective prescribing of hormone therapy.

From the FDA Drug Label

Estradiol tablets are a medicine that contains estrogen hormones. Estradiol is used to: reduce moderate to severe hot flashes You and your healthcare provider should talk regularly about whether you still need treatment with estradiol. Do not use estrogens with or without progestins to prevent heart disease, heart attacks, or strokes. Using estrogens with or without progestins may increase your chances of getting heart attacks, strokes, breast cancer, and blood clots. Using estrogens with progestins may increase your risk of dementia Tell your healthcare provider: about all of your medical problems about all the medicines you take

The important questions to ask before prescribing hormone therapy to a 54-year-old postmenopausal female presenting with symptoms of brain fog, hot flashes, and night sweats include:

• Medical History: What is the patient's medical history, including any previous cancers, heart disease, or stroke?
• Current Medications: What medications is the patient currently taking, including any prescription or nonprescription medicines, vitamins, and herbal supplements?
• Symptom Severity: How severe are the patient's symptoms, and how are they affecting her daily life?
• Treatment Goals: What are the patient's treatment goals, and is she interested in hormone therapy to reduce symptoms or prevent osteoporosis?
• Alternative Treatments: Have alternative treatments, such as lifestyle changes or non-hormonal medications, been considered or tried?
• Risk Factors: Does the patient have any risk factors for adverse effects from hormone therapy, such as a history of blood clots or breast cancer? 2

From the Research

Important Considerations Before Prescribing Hormone Therapy

Before prescribing hormone therapy to a 54-year-old postmenopausal female presenting with symptoms of brain fog, hot flashes, and night sweats, the following questions must be asked:

• What are the patient's medical history and current health status, including any history of breast cancer, venous thromboembolism, or other conditions that may be affected by hormone therapy 3, 4, 5?
• What are the patient's symptoms and how are they affecting her daily life, and are there any other treatment options that have been considered or tried 4, 6?
• What is the patient's attitude towards hormone therapy, and are there any concerns or fears that she may have, such as the risk of breast cancer 7?
• What is the most appropriate regimen of hormone therapy for this patient, including the type and dose of estrogen and progestogen, and the duration of treatment 3, 4?
• How will the patient be monitored and followed up during treatment, and what are the criteria for adjusting or stopping treatment 4, 6?

Benefits and Risks of Hormone Therapy

The benefits of hormone therapy for this patient may include:

• Relief from vasomotor symptoms such as hot flashes and night sweats 4
• Improvement in vaginal dryness and other genitourinary symptoms 4
• Protection from osteoporotic fractures and other chronic diseases 4, 6 However, the risks of hormone therapy must also be considered, including:
• Increased risk of breast cancer and venous thromboembolism 3, 4, 5
• Potential adverse effects on hemostasis and thrombosis 5
• Individual variation in response to hormone therapy, and the need for personalized treatment 7, 6

Patient Education and Involvement

It is essential to involve the patient in the decision-making process and to provide her with accurate and evidence-based information about the benefits and risks of hormone therapy 3, 7, 6. This includes:

• Discussing the patient's individual risk factors and medical history 3, 4
• Explaining the different types and regimens of hormone therapy, and the potential benefits and risks of each 3, 4
• Encouraging the patient to ask questions and express her concerns and preferences 7
• Providing ongoing education and support during treatment, and adjusting the treatment plan as needed 4, 6