Hormone therapy (HT)

N95.1-2/N95.8-9

Indications:

Short-term symptomatic relief for severe menopausal symptoms.
For menopausal women, treatment should be ≤ 5 years.
Risk-benefit assessment should be individualised in all patients.

Contra-indications include:

  • Known or suspected estrogen-dependent malignant tumours (such as endometrial cancer).
  • Coronary heart disease.
  • Active liver disease.
  • Women ≥60 years of age.
  • Current, past or suspected breast cancer.
  • Thrombophilia.
  • Undiagnosed genital bleeding.
  • Previous idiopathic or current venous thromboembolism.
  • Untreated endometrial hyperplasia.
  • Porphyria cutanea tarda.

GENERAL MEASURES

Prior to starting HT:

  • Do breast and gynaecological examination.
  • Cervical screening.
  • Where the facility is available, arrange mammography before starting HT. However, lack of access to mammography should not delay HT if indicated for severe menopausal symptoms if the woman has no other special risk factors for breast cancer (e.g.: family history of breast cancer in first degree relative).

LoEI [50]

MEDICINE TREATMENT (Doctor initiated)

Uterus present (no hysterectomy)

HT can be offered as sequentially opposed or continuous combined preparations. Continuous combined preparations are often preferred if the woman had her last menstrual period (menopause) over a year ago, as they will not usually cause bleeding then. For women who are still menstruating or have recently stopped, sequentially opposed preparations are preferred and will result in regular menstrual periods, whereas continuous combined may result in irregular bleeding.

CONTINUOUS COMBINED THERAPY
- Estradiol/norethisterone acetate, oral, 1mg/0.5mg for 28 days.
OR
- Estradiol/norethisterone acetate, oral, 2mg/1mg for 28 days.
OR
- Conjugated estrogens, oral, 0.3–0.625 mg for 28 days.
AND
Medroxyprogesterone acetate, oral, 2.5–5mg daily for 28 days.

OR

SEQUENTIALLY OPPOSED THERAPY
Estradiol valerate/cyproterone acetate, oral:
- Estradiol valerate, oral, 2 mg for 11 days
- Estradiol valerate/cyproterone acetate, oral, 2mg/1mg for 10 days
- Placebo, oral, for 7 days.
OR
- Estradiol valerate, oral, 1–2 mg daily for 21 days.
ADD
Medroxyprogesterone acetate, oral, 5 -10 mg daily from day 12–21.
- Followed by no therapy from day 22–28.
OR
- Conjugated estrogens, oral, 0.3–0.625 mg daily for 21 days.
ADD
- Medroxyprogesterone acetate, oral, 5–10 mg daily from day 12–21.
- Followed by no therapy from day 22–28.

LoEIII [51]

Note: Where a dose range is provided start at the lowest possible dose to alleviate symptoms. The need to continue HT should be reviewed annually.

Women with no uterus (post-hysterectomy)

HT is given as estrogen only.

  • Estradiol valerate, oral, 1–2 mg daily.

OR

  • Conjugated estrogens, oral, 0.3 mg daily to a maximum of 1.25 mg daily.

REFERRAL

  • Premature menopause, i.e. < 40 years of age.
  • Severe osteoporosis
  • Management difficulties, e.g. where oestrogen therapy is contra-indicated, poorly tolerated, or ineffective. .
  • Post-menopausal bleeding.
  • If HT needed (symptoms persist) after 5 years of HT or woman ≥ 65 years.