What factors should be considered when deciding between systemic and local HRT for a patient?

When deciding between systemic and local hormone replacement therapy (HRT) for a patient, several key factors should be considered. Systemic HRT is generally offered to manage vasomotor symptoms and other systemic menopausal symptoms, while local HRT (such as vaginal oestrogen) is primarily used for genitourinary symptoms associated with menopause. Local HRT results in minimal systemic absorption and is unlikely to have significant effects throughout the body, making it preferable for isolated genitourinary symptoms or when systemic HRT is contraindicated or not desired. Systemic HRT is appropriate for women with an intact uterus (combined HRT) or those who have had a hysterectomy (oestrogen-only HRT), and the choice should be individualized based on symptom profile, risks, and patient preference.

Additional considerations include the patient's personal and family history of hormone-sensitive cancers (e.g., breast cancer), cardiovascular risk factors, co-morbidities such as diabetes or hypothyroidism, and the severity and type of menopausal symptoms. For example, systemic HRT may be avoided or used cautiously in women with a history of breast cancer, whereas local vaginal oestrogen may still be offered for genitourinary symptoms. The route of administration (oral vs transdermal) for systemic HRT can also be influenced by cardiovascular risk, with transdermal preferred in women at increased cardiovascular risk. Shared decision-making is essential, discussing benefits, risks, and patient preferences, and treatment should be regularly reviewed and adjusted as needed.

In summary, the decision between systemic and local HRT depends on the symptom type and severity, risk profile including cancer and cardiovascular risks, contraindications, and patient preference, with local HRT favored for isolated genitourinary symptoms and systemic HRT for broader menopausal symptom control ¹,².