What information should be obtained from a patient before initiating Hormone Replacement Therapy (HRT)?

Pre-HRT Assessment: Essential Patient Information

Before initiating HRT, you must systematically evaluate contraindications, assess individual risk factors, and determine the appropriate regimen based on uterine status, smoking history, and personal/family cancer history.

Absolute Contraindications to Screen For

• Undiagnosed vaginal bleeding - This requires investigation before starting HRT, as it may indicate endometrial cancer 1
• Current or history of breast cancer - Estrogen may increase risk of hormone-sensitive cancers 1
• Current or history of endometrial cancer - Unopposed estrogen increases endometrial cancer risk 2-12 fold 1
• Active or recent venous thromboembolism (VTE) - HRT increases VTE risk, particularly in the first 1-2 years 1
• Active or recent arterial thromboembolic disease - Including myocardial infarction or stroke 2
• Known thrombophilic disorders - These significantly increase clotting risk with estrogen 1
• Active liver disease or impaired hepatic function - Estrogens are poorly metabolized with liver impairment 1
• Pregnancy or lactation - HRT is contraindicated in these states 1

Critical Medical History Elements

Cardiovascular Risk Assessment

• History of coronary heart disease, myocardial infarction, or stroke - These are contraindications to systemic HRT 2, 1
• Current blood pressure status - Hypertension is not an absolute contraindication, but transdermal estradiol is preferred over oral formulations in hypertensive women 3
• Lipid profile and diabetes status - Estrogen therapy may cause hypertriglyceridemia leading to pancreatitis in women with pre-existing hypertriglyceridemia 1

Uterine Status (Critical for Regimen Selection)

• Presence or absence of uterus - Women with intact uteri must receive progestin combined with estrogen to prevent endometrial hyperplasia 3, 4, 1
• History of hysterectomy - Unopposed estrogen therapy is appropriate for women without a uterus 4
• History of endometriosis - Even post-hysterectomy, progestin should be added if residual endometriosis is known, due to rare cases of malignant transformation 1

Cancer History and Risk

• Personal history of hormone-dependent cancers - Breast cancer and endometrial cancer are generally contraindications 2, 1
• Family history of breast or uterine cancer - Family history alone (without personal history) is NOT a contraindication to HRT 4
• BRCA1/2 mutation status - HRT is an option for BRCA carriers without personal breast cancer history after prophylactic oophorectomy 3

Smoking Status (Determines Route of Administration)

• Current smoking status - Smoking is a relative contraindication to oral HRT but not to transdermal HRT 4
• If patient smokes, transdermal estrogen preparations must be used exclusively 4

Additional Medical Conditions to Assess

• Migraine history - Migraine is not a contraindication, but dose, route, or regimen may need adjustment if migraines worsen 3
• Thyroid disease - Women on thyroid replacement may require increased doses due to estrogen-induced elevation of thyroid-binding globulin 1
• Conditions affected by fluid retention - Cardiac or renal dysfunction warrant careful observation, as estrogens may cause fluid retention 1
• Hypoparathyroidism - Use caution as estrogen-induced hypocalcemia may occur 1
• Asthma, diabetes, epilepsy, porphyria, systemic lupus erythematosus, hepatic hemangiomas - Estrogen may exacerbate these conditions 1

Current Medications Review

• Aromatase inhibitors - Vaginal estrogen may interfere with their efficacy in breast cancer survivors 2
• Tamoxifen use - Certain SSRIs (paroxetine, fluoxetine) should not be used concurrently 2
• Thyroid hormone replacement - Doses may need adjustment with HRT initiation 1
• Anticoagulants - Estrogen affects multiple coagulation factors 1

Symptom and Indication Assessment

• Severity of vasomotor symptoms (hot flashes, night sweats) - HRT is indicated for moderate to severe symptoms 3
• Genitourinary symptoms - Vaginal dryness, dyspareunia, urinary symptoms 3
• Osteoporosis risk factors - Including premature menopause (before age 45), early menopause, low bone mineral density 3, 2
• Age at menopause and time since menopause - Women within 10 years of menopause have the most favorable benefit-risk profile 3, 5

Laboratory and Baseline Testing

• Baseline lipid profile - To assess cardiovascular risk and monitor changes 2
• Blood pressure measurement - Essential baseline and monitoring parameter 2
• Glucose monitoring - Particularly in women with diabetes risk 1
• Bone density assessment - If osteoporosis prevention is a primary indication 4
• FSH and estradiol levels - May be useful for confirming menopause in younger women or those with hypogonadism, but not routinely needed for managing vasomotor symptoms 1

Patient Counseling Points to Address

• Expected benefits - Relief of vasomotor symptoms, prevention of bone loss, potential cardiovascular benefits if started early 3, 6
• Risks to discuss - Small increased stroke risk, breast cancer risk with long-term estrogen-progestin use (particularly after 5 years), VTE risk especially in first 1-2 years 3, 1, 6
• Bleeding patterns - Women with intact uteri on cyclic regimens will have withdrawal bleeding 3
• Duration of therapy - Use lowest effective dose for shortest duration needed, though women may continue if benefits outweigh risks with regular reassessment 3, 6
• Alternative treatments tried - Document previous non-hormonal approaches for symptom management 2

Common Pitfalls to Avoid

• Failing to distinguish between systemic and topical estrogen risks - Topical vaginal estrogen has minimal systemic absorption and different risk profile 2
• Using oral estrogen in smokers - Always use transdermal route in current smokers 4
• Prescribing unopposed estrogen to women with intact uteri - This dramatically increases endometrial cancer risk 3, 1
• Not considering 17-beta estradiol as preferred over conjugated equine estrogens or ethinylestradiol 3
• Overlooking the timing hypothesis - HRT initiated within 10 years of menopause has more favorable benefit-risk than when started later 3, 5