Prescribing HRT – which preparation to use?

Page from back of MIMs is for information only. Is a useful list of all the HRT preparations and their constituents.

Use the ‘my formulary’ to decide which preparation (the name) to use in the following cases:

(Assume that patients have a uterus and no risk factors unless otherwise stated ).

  1. 44 year old post hysterectomy and BSO.
  2. 48 year old. LMP 10 months ago. Nocturnal sweats.
  3. 48 year old. LMP 13 months ago. Flushes and sweats.
  4. 54 year oldcurrently on 1mg cyclical combined preparation for past 2 years.
  5. 49 year old. Had IUS inserted 2 years ago for menorrhagia. Amenorrhoeic for 18 months. Now has disabling sweats.
  6. 52 year old. LMP 6 months ago. Hot flushes ++. Wishes tablets.
  7. 51 year old. Had hysterectomy with ovarian conservation 10 years ago. Now nocturnal sweats and vaginal dryness.
  8. 55 year old. Had IUS inserted aged 49 for contraception. Amenorrhoeic ever since. Is tired out after struggling with nocturnal sweats and flushes for 3 years.
  9. 61 year old. Stopped kliovance 18 months ago when she was nearing 60. Persists with extremely uncomfortable and distressing flushes and night sweats. Exhausted. She is fully aware of the risks of HRT, especially when > 60 years old. Wishes to restart.

Answers

Prescribing HRT – answers.

  1. Elleste solo 1mg tablets first line or Evorel 25 patch. Start at lower dose. May need to increase dose. Women post hysterectomy with ‘surgical’ menopause often need higher doses. Start low and work up.
  2. Cyclical combined. Elleste duet 1mg. Or, Mirena + elleste or Evorel 25 (especially if menorrhagia as well). Or, could consider 20mcg COC until age 50, which helps with flushing.
  3. Continuous combined. Can accept irregular bleeding during 1st 3 months, consider pathology or hysteroscopy beyond this. Some authorities suggest only using if > 2 years post LMP if the patient is < 50. eg. Kliovance (1mg). note: evorel duet conti has no 25mcg strength. Only option for lowest dose transdermal estrogen is evorel 25 + either utrogestan (micronized progesterone) 100mg od or MPA (medroxyprogesterone acetate) 5mg od.
  4. Can be changed to continuous combined eg. kliovance. Can try changing after 1 year of cyclical use. Note: more complete endometrial protection with continuous combined preparations.
  5. Just need to add back oestrogen. Offer tablets or patches. Elleste Solo 1mg or Evorel 25 is the starting dose. IUS can be used as endometrial protection for 5 years.
  6. Cyclical combined. Elleste duet 1mg
  7. Add back oestrogen only preparation .Elleste solo 1mg or evorel 25. Remember the use of topical oestrogens eg. ovestin (estriol) cream or vagifem 10mcg pessaries (estradiol), rather than systemic HRT, if vaginal dryness is the only symptom. Thought not to be associated with the risks of systemic HRT, recent data backs this up. Can be used long term. Note that the PIL includes the precautions advised for systemic HRT. Can alarm patients. Warn them to expect this.
  8. IUS is no longer working as endometrial protection (up to 5 years). FSRH states that once women reach age 55 contraception is no longer required (as 95.9% of women are postmenopausal at this stage. So, can remove IUS with no further contraception needed. Can then use continuous combined HRT eg. Kliovance (rather than Elleste Duet Conti – see 3.) or Evorel 50 patch + continuous utrogestan or MPA tabs.
  9. As aged >60y, transdermal oestrogen is the preferred option. Also, need to use lowest dose possible ie. 25 patch. There is no combination patch, therefore, suggest Evorel 25 patch (or Estrogel 1-2 measures) with oral micronized progestogen (utrogestan) 100mg daily, continuously.