Dr Kola Tytler MBBS CertHE MBA MSt MRCGPClinical Lead • iatroX
Contraindications and precautions
- The supplied extracts do not provide a complete list of systemic HRT contraindications; they identify pregnancy, jaundice or deterioration in liver function, a significant increase in blood pressure, and new-onset migraine-type headache as reasons to discontinue treatment SmPC Premarin.
- Dydrogesterone is contraindicated with current or previous meningioma NICE CKS.
- Conditions requiring close supervision—not presented as automatic contraindications in these extracts—include fibroids/endometriosis, thromboembolic risk factors, a family history of breast cancer, hypertension, liver disorders, diabetes, gallstones, migraine, SLE, previous endometrial hyperplasia, epilepsy, asthma and otosclerosis SmPC Premarin.
- Seek specialist menopause advice where contraindications exist, a condition may be affected by HRT, or the appropriate treatment is uncertain NICE CKS.
Examples of HRT preparations
- Systemic combined HRT: oestrogen with a progestogen such as micronised progesterone, dydrogesterone, norethisterone or medroxyprogesterone; combined patches contain norethisterone or levonorgestrel NICE CKS.
- Separate components: oestrogen with oral micronised progesterone, for example 200 mg/day for 12 days each month in a low-dose sequential regimen, or oestrogen with a 52 mg levonorgestrel intrauterine system for endometrial protection NICE CKS.
- Local vaginal oestrogen: estradiol tablets such as Vagifem, an estradiol ring such as Estring, or estriol cream such as Ovestin NICE CKS.
- People with a uterus require a progestogen alongside systemic oestrogen to minimise endometrial hyperplasia and cancer risk NICE CKS.
HRT versus DMPA
The context describes HRT as treatment for menopause-associated symptoms and identifies oral medroxyprogesterone acetate as an HRT progestogen option—10 mg/day for 12 days each month in a low-dose sequential regimen, or a minimum of 2.5 mg/day in a continuous combined regimen NICE CKS. The extracts do not describe depot medroxyprogesterone acetate, so they do not support a comparison of DMPA’s indication, contraceptive action, dosing or mechanism with HRT NICE CKS.
Why amenorrhoea can occur with HRT
- Continuous combined HRT: oestrogen and progestogen are taken daily, and amenorrhoea is expected by six months after initiation; this regimen is usually recommended after at least 12 months of amenorrhoea before starting HRT NICE CKS.
- Sequential/cyclical HRT: absence of bleeding reflects an atrophic endometrium NICE CKS.
- If bleeding is absent on a cyclical regimen, exclude pregnancy in perimenopausal women or those with premature ovarian insufficiency, and check adherence if the progestogen is taken separately NICE CKS.