How to manage HRT provision without face to face consultations during COVID-19 healthcare restrictions

It is okay to prescribe up to 12 months of HRT providing you are happy with the HRT check. This is based on NICE guideline [NG23]. Review each treatment for short-term menopausal symptoms:

• at three months to assess efficacy and tolerability
• annually thereafter unless there are clinical indications for an earlier review (such as treatment ineffectiveness, side effects or adverse events).

1. HRT converter: how to convert oestradiol gels and patches

• 1.5mg oestradiol gel = 50mcg patch = 2mg oral oestradiol are reasonably bioequivalent

2. HRT availability and equivalents:

• if you can’t get hold of an oestrogen-only patch, then consider swapping to gel
• if swapping patches, brands will differ because of glue. Some patches stay on better than others
• beware weekly and twice-weekly regimens when prescribing patches
• for further information on equivalents, see the full guideline

3. HRT side-effects and trouble shooting:

• the main side effects of taking oestrogen include bloating, breast tenderness or swelling, feeling sick, leg cramps, headaches, indigestion. Consider changing to transdermal or if on transdermal adjusting dose
• the main side effects of taking progestin include breast tenderness, swelling in other parts of the body, headaches or migraines, mood swings, depression, acne, and gastrointestinal side effects. If on oral, consider swapping the progestin to dydrogesterone, or if on combined patch consider swapping to oestradiol only with oral progesterone e.g. micronised progesterone or medroxyprogesterone acetate. 

4. Unscheduled vaginal bleeding and HRT:

• the RCOG, BSGE and BGCS recommend remote consultation and minimising gynaecological procedures. In practice, this means that as primary care practitioners, access to hysteroscopy will be limited.
• as usual, unscheduled bleeding of any duration consider pregnancy, STI and cervical cytology as appropriate. Please also see the PCHWF’s resource How to manage women presenting with abnormal vaginal bleeding in primary care without face-to-face contact
• follow on from recent advice from the British Menopause Society
• unscheduled bleeding <6 months (common in first three to four months of HRT).
• Intra-uterine systems (IUS) and HRT:
  • keep IUS in situ and add in progestin MP, MPA or NET or swap to cyclical progestogen regimen (see the PCWHF HRT prescribing resource)
• Cyclical HRT:
  • increase progestin dose (MPA 20 mg or MP 300 mg for 12–14 days for 28-day cycle)
  • or duration (e.g. MPA 20 mg for 21 days of 28-day cycle)
  • or type (e.g. medroxyprogesterone acetate has good endometrial affinity and may provide the best bleed control)
• Continuous combined HRT:
  • increase progestin dose (e.g 100 mg MP to 200 mg daily, 5 mg MPA to 10 mg)
  • swap progestin (to MPA or NET)
• If unscheduled bleeding > 6 months consider further investigation (e.g. pelvic ultrasound and endometrial biopsy) or write for advice and guidance from local hysteroscopy service.

5. NICE (NG23) recommends analysis of individualised long-term benefits and risks of hormone replacement therapy:

• see NG23 for recommendations on the benefits and risks of HRT in relation to venous thromboembolism, cardiovascular risks, breast cancer, and osteoporosis.

6. Metabolic considerations:

• if patients are on levothyroxine, they often get on better with a transdermal oestrogen than oral (due to the actions of sex hormone binding globulin). Type 2 diabetes—no need to stop HRT in diabetic patients, consider swapping to patch or gels for less metabolic impact.

7. IUS rules

• Mirena for HRT
  • if Mirena is > five years add oral progestin such as MPA 5–10 mg or Utrogestan 100 mg daily
  • if Mirena is inserted for the purpose of HRT, the FSRH recommendation is that it can stay in for five years (licensed for four years) with oestrogen therapy but if is more than five years then her HRT should be changed from oestrogen only to a combined HRT preparation.
• Mirena for contraception
  • Mirena is licensed for five years use for contraception. FSRH advice is that if the Mirena is between five and seven years since it was changed then contraceptive cover continues. So, no need to change now. An IUS placed over 45 years previously will still act as contraception for a perimenopausal woman until age 55 years

8. Please remember vaginal health

• vaginal oestrogen has minimal systemic absorption and is widely considered to be safe

9. Use of testosterone

• starting testosterone now in primary care is not ideal, as it requires laboratory monitoring which is not available. Patients who are stable on testosterone should continue the established dose
  • starting testosterone requires laboratory testing which is not currently available
  • write for advice and guidance to gynae/menopause specialist if not confident starting
• testosterone can be essential for maintaining quality of life particularly those with POI and/or surgical menopause. If there are signs of androgen deficiency in a woman who is on adequate oestrogen replacement, then testosterone replacement should may be considered if the clinician feels confident to do so
• for clear guidance: thebms.org.uk/publications/tools-forclinicians/testosterone-replacement-in-menopause/