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Overview

The Primary Care Women’s Health Forum has produced this guide for primary care practitioners in order to provide support for hormone replacement therapy (HRT) provision during COVID-19 healthcare restrictions.

Menopause management checklist tools for remote consultations in primary care

Table 1: Tool for initiating HRT by remote consultation

CHECKLISTY/NTOP TIPS AND WHERE TO FIND MORE INFORMATION, BASED ON NICE MENOPAUSE: DIAGNOSIS AND MANAGEMENT[A]

BMI <30kg/m2

y/n

Watch for BMI > 30kg/m2, see risk review.

Blood pressure normal

y/n

HRT OK if hypertension well controlled, if no BP available see tip no. 5 on PCWHF tips on HRT provision during COVID-19 healthcare restrictions.

Progestogen required

y/n

Progestogen required unless hysterectomy or 52mgLNG IUS within 5 years document in notes

Last menstrual period <12 months

y/n

Document perimenopause or post menopause as appropriate

Regular medications

 

Check GP notes

Past medical history

 

Check GP notes

Smoker

y/n

How much?

Alcohol >14 units/week

y/n

Document number of units

Cervical Cytology up to date

y/n

Check GP notes

 

QUESTIONS FOR PATIENT

Do you feel that your symptoms are related to the menopause?

y/n

See Rock My Menopause for symptoms of menopause

Which symptoms are you

most concerned about?

 

Document in notes

Signpost to ‘Symptom Tracker’ on Rock My Menopause

Are you hoping to be prescribed HRT?

y/n

If Yes – Signpost to PIL ‘HRT in a nutshell’

If No – Signpost to ‘Alternatives to HRT’

Have you found out about benefits and potential long-term risks of using HRT?

y/n

Document the source of information or signpost to RCOG menopause information webinar 

and NHS

 

Do you have any vaginal dryness or discomfort?

y/n

If Yes – Offer vaginal oestrogen and signpost

pcwhf.co.uk/resources/vulval-skin-care/

rockmymenopause.com/portfolio-item/vaginal-dryness

Are you attending recommended

screening programmes?

y/n

Reiterate advice regarding cytology, mammography and breast awareness

pcwhf.co.uk/resources/the-vulval-pain-society-leaflet-smearswithout-tears

nhs.uk/conditions/breast-cancer-screening

Any concerns about vaginal bleeding?

y/n

Please follow NICE guidance as appropriate

HMB nice.org.uk/guidance/ng88

PMB nice.org.uk/guidance/ng12/chapter/1-Recommendationsorganised-by-site-of-cancer#gynaecological-cancers

Are you sexually active?

y/n

Do you have problems in this area?

Are you at risk of pregnancy?

y/n

If in doubt advise contraception until 55yrs[B]

Have you recently changed

your sexual partner?

y/n

Establish STI risk

[A] NICE. Menopause: diagnosis and management. (2015). NICE guideline [NG23] Published date: November 2015 Last updated: December 2019. Available at: nice.org.uk/guidance/ng23

[B] FSRH Guidance for contraception for women over 40. (2019). Available at: fsrh.org/documents/fsrh-guidancecontraception-for-women-aged-over-40-years-2017/fsrh-guidelinecontraception-aged-over-40-sep-2019.pdf

Table 2: Tool for reviewing HRT by remote consultation

HRT REVIEW CHECKLISTY/NTOP TIPS AND WHERE TO FIND MORE INFORMATION

BMI < 30kg/m2

y/n

Watch for BMI > 30kg/m2, see risk review.

Blood pressure normal

y/n

HRT OK if hypertension well controlled

Progestin required

y/n

Unless hysterectomy or 52mgLNG IUS within 5 years

HRT supply difficulty?

y/n

For HRT converter see PCWHF tips on HRT provision during COVID-19 healthcare restrictions.

QUESTIONS FOR PATIENT

Is the HRT helping symptoms?

y/n

 

Any side effects?

y/n

For HRT side effects troubleshooter, see below

Any change to your health since

your last HRT check?

y/n

Document in notes

Any change to your other

medications since your last HRT

check?

y/n

Document in notes

Do you have any vaginal dryness or discomfort?

y/n

If Yes – Offer vaginal oestrogen and see PIL on vulval care

pcwhf.co.uk/resources/vulval-skin-care

Are you attending recommended

screening programmes?

y/n

Reiterate advice regarding cytology, mammography and breast awareness, see PIL

pcwhf.co.uk/resources/the-vulval-pain-society-leaflet-smears-without-tears

Any concerns about vaginal

bleeding?

y/n

For tips on bleeding, see PCWHF tips on HRT provision during COVID-19 healthcare restrictions.

Do you need contraception?

y/n

If in doubt, advise contraception until 55yrs[A]

RISK REVIEW BY PRIMARY HEALTHCARE PRACTITIONER

Venous Thromboembolism, new risk?

y/n

Consider transdermal oestrogen if risk, see PCWHF tips on HRT provision during COVID-19 healthcare restrictions.

Arterial, new risk?

y/n

Consider transdermal oestrogen if risk, see PCWHF tips on HRT provision during COVID-19 healthcare restrictions.

Breast, new risk?

y/n

For counselling tip, see PCWHF tips on HRT provision during COVID-19 healthcare restrictions.

Bone, new risk?

y/n

HRT protects bone density, see PCWHF tips on HRT provision during COVID-19 healthcare restrictions.

Metabolic, new risk?

y/n

If liver disease, malabsorption, thyroid disorder or diabetic consider transdermals

Might testosterone add benefit?

y/n

See tip 9 in PCWHF tips on HRT provision during COVID-19 healthcare restrictions and pcwhf.co.uk/resources/10-top-tips-on-testosterone-use-for-women

Next HRT review OK for 12 months?

y/n

12 months is OK unless you have concerns

[A] FSRH Guidance for contraception for women over 40. (2019).  Available at: fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/fsrh-guideline-contraception-aged-over-40-sep-2019.pdf

Table 3: HRT prescribing tool

OESTROGEN ONLY(no uterus or IUS)SEQUENTIAL COMBINED(uterus – monthly bleed)CONTINUOUS COMBINED (uterus – no bleed)Lmp > 1 yr ago if > 50yrsLmp > 2yrs if < 50 yrs

PATCHES

Available as brands

Twice weekly patch

E2 40/80

E2 25/50/75/100

E2 25/37.5/50/75/100

E2 50/75/100

Once weekly patch

E2 50 (mcg/24hrs)

Mix and Match

E2 + MPA 10mg cyclical

E2 + MP 200mg cyclical

Available as brands

E2 50mcg + LNG 10mcg cyclical

E2 50mcg + NET 170mcg cyclical

Mix and Match

E2 + MPA 5-10mg conti

E2 + MP 100mg conti

Available as brands

E2 50mcg + NET170mcg

E2 50mcg + LNG 7mcg

GELS

Daily

E2 Pump-Pack 0.06%

E2 gel sachets 0.5/1mg

E2 + MPA 10mg cyclical

E2 + MP 200mg cyclical

E2 + MPA 5-10mg conti

E2 + MP 100mg conti

ORAL HRT

CEE 0.3/0.625/1.25mcg

No branded option

CEE 0.3/1.5MPA continuously

E2 0.5mg (use half of 1mg)

No branded option

Available as brand

E2 0.5+ 2.5mg dydro conti

E2 1mg

Mix and Match

E2 1mg + MPA 10mg cyclical

E2 1mg + MP 200mg cyclical

Available as brands

E2 1mg + cyclical dydro

E2 1mg with cyclical NET

Mix and Match

E2 1mg + MPA 5-10mg conti

E2 1mg + MP 100mg conti

Available as brands

E2 1mg + 5mg dydro conti

E2 1mg + NET 0.5mg conti

E2 1mg + MPA conti

E2 2mg

Mix and Match

E2 2mg + MPA 10mg cyclical

E2 2mg + MP 200mg cyclical

Available as brands

E2 2mg + with cyclical dydro

E2 2mg with cyclical NET

E2 2mg + MPA long cycle

Mix and Match

E2 2mg + NET1mg conti

E2 2mg + MPA conti

Available as brands

E2 2mg + NET 1mg conti

E2 2mg + MPA 5mg conti

Estradiol valerate 1mg/2mg

No branded option

No branded option

No branded option

No branded option

Tibolone 2.5mg

TABLE KEY

CEE Conjugated equine estrogen; Conti – Continuous regime; Cyclical progestogen regime—for last 14-28 days of each cycle; Dydro—Dydrogesterone (mildly anti androgenic progesterone derived progestin); E2—Estradiol; LNG—Levenorgestrel (androgenic); MP—Micronised progesterone (Body identical); MPA—Medroxyprogesterone acetate (progestogenic with high endometrial affinity); NET—Norethisterone (androgenic progestin)

Tips on HRT provision 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] (link to guidance). 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 regimes 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 insert cohistory 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 regime (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 (link) 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/

Full guideline available from:

https://pcwhf.co.uk/resources/how-to-manage-hrt-provision-without-face-to-face-consultations-during-covid-19-healthcare-restrictions/

Primary Care Women’s Health Forum. How to manage HRT provision without face to face consultations during COVID-19 healthcare restrictions. April 2020.

Published date: 30 April 2020.