Synopsis
Select systemic HRT by uterine status, menopausal stage, route and risk while applying product contraindications, proportional endometrial protection, licensed doses and balanced absolute-risk communication.
- Offer combined oestrogen-progestogen HRT to someone with a uterus and oestrogen-only HRT after total hysterectomy; residual endometriosis or uncertain residual endometrium needs specialist individualisation.
- Use a sequential combined regimen while periods continue or early in the transition, and a continuous combined regimen after menopause when a bleed-free regimen is appropriate.
- Start with a licensed low or standard dose, review after three months and titrate to the lowest dose that controls the agreed symptoms; high or off-label dosing is exceptional.
- Prefer transdermal oestrogen when VTE risk is increased, including BMI above 30 kg/m², because NICE reports no increased VTE risk with transdermal HRT but an increase with oral HRT.
- Systemic product labels contraindicate use with known, past or suspected breast cancer, oestrogen-dependent cancer, unexplained bleeding, untreated hyperplasia, current or previous VTE, thrombophilia, active or recent arterial thromboembolism, active liver disease and porphyria.
- A previous coronary event or stroke requires specialist discussion: NICE supports individualised consideration, while active or recent arterial disease remains a product-label contraindication.
- HRT does not provide contraception, and transdermal delivery does not remove the need for progestogen when a uterus is present.
- Review efficacy, adverse effects, bleeding, blood pressure and evolving risk at three months then annually; there is no universal maximum duration when benefits continue to outweigh risks.
Key red flags
Sudden breathlessness, pleuritic pain, haemoptysis or unilateral painful leg swelling requires urgent venous-thromboembolism assessment and interruption of systemic HRT.
New facial or limb weakness, speech disturbance, severe acute headache or retinal symptoms requires an emergency stroke pathway.
Jaundice, dark urine, pale stools or marked right-upper-quadrant symptoms suggests liver injury and requires treatment interruption and liver assessment.
Undiagnosed genital bleeding or known untreated endometrial hyperplasia must be investigated before systemic oestrogen is started.
A new breast mass, nipple change or diagnosis of breast cancer needs prompt breast assessment; systemic HRT is stopped when breast cancer is diagnosed.
Investigation priorities
Identify systemic-HRT contraindications, route modifiers and a baseline for monitoring.
Management branches
Systemic HRT is desired after benefits, risks and alternatives have been discussed.
- Confirm uterine status, menstrual stage, contraception, symptom priorities and whether previous endometriosis alters the usual oestrogen-only approach after hysterectomy.
- Select sequential combined, continuous combined or oestrogen-only treatment and ensure progestogen exposure is proportional to the oestrogen dose.
- Choose oral or transdermal delivery from VTE, stroke, migraine, liver, metabolic, adherence and preference considerations.