HRT Quick Reference Card for Clinicians
Based on NAMS 2022 Position Statement and NICE NG23 (updated 2024)
Systemic estrogen therapy
| Type | Route | Common products | Starting dose | Key considerations |
|---|---|---|---|---|
| Estrogen only (Hysterectomy patients) |
Transdermal patch | Estradot, Climara, Evorel | 25-50 mcg/day | Preferred route. No first-pass hepatic effect. Lower VTE risk vs oral. Change 1-2x/week. |
| Transdermal gel | Oestrogel, Sandrena | 0.5-1.0 mg/day | Flexible dosing. Apply to skin daily. Allow to dry before dressing. | |
| Oral | Estrofem, Progynova | 0.5-1.0 mg/day | Higher VTE risk than transdermal. Consider transdermal for BMI >30, migraine, hypertension. |
| Type | Route | Common products | Starting dose | Key considerations |
|---|---|---|---|---|
| Combined E+P (Intact uterus) |
Patch + oral P | Estradiol patch + micronized progesterone (Utrogestan) | Patch 25-50 mcg + P 100-200 mg | Micronized progesterone preferred. Better side-effect profile. Cyclical (12-14 days/month) or continuous. |
| Combined patch | FemSeven Combi, Evorel Conti | Per product | Convenient single patch. Available as sequential or continuous. | |
| Oral combined | Femoston, Kliogest | 1/10 or 2/10 (sequential) | Sequential for peri (still cycling). Continuous combined for 12+ months post last period. | |
| IUD + Estrogen | LNG-IUS + patch/gel | Mirena + estradiol | Standard | Mirena provides endometrial protection + contraception. Licensed for HRT progestogen component. |
Local and adjunct therapies
| Type | Route | Common products | Starting dose | Key considerations |
|---|---|---|---|---|
| Vaginal estrogen | Vaginal | Vagifem, Ovestin cream, Estring | 10 mcg tab or 0.5 mg cream | Safe for most women including breast cancer survivors (discuss with oncologist). Minimal systemic absorption. Can use alongside systemic HRT. |
| Testosterone | Transdermal | Androfeme 1%, compounded cream | 5 mg/day (1/10 of male dose) | For hypoactive sexual desire. Off-label in most countries. Monitor levels at 3-6 months. Watch for androgenic side effects. |
| DHEA | Vaginal | Intrarosa (prasterone) | 6.5 mg/day | For vulvovaginal atrophy. Converts locally to estrogen and testosterone. |
Absolute contraindications
- Undiagnosed vaginal bleeding
- Current or recent breast cancer
- Active VTE or PE
- Active liver disease
- Known thrombophilia (for oral route)
- Pregnancy
Use with caution / specialist referral
- History of breast cancer (individualize)
- History of VTE (transdermal preferred)
- CVD or stroke history
- Migraine with aura (transdermal preferred)
- Active gallbladder disease (transdermal preferred)
- Endometriosis
- Fibroids
Monitoring schedule
| Timepoint | Actions | Notes |
|---|---|---|
| Baseline | BP, BMI, breast exam, cervical screening status, VTE/CVD risk assessment | Mammography per national screening schedule. Lipid profile and glucose if risk factors present. |
| 3 months | Review symptom response, side effects, bleeding pattern. BP check. | Dose adjustment if needed. Most side effects settle by 3 months. If testosterone started, check levels. |
| 6-12 months | Full review. Symptom check, BP, weight. Assess ongoing need. | Transition from sequential to continuous combined if appropriate (12+ months post last period). |
| Annually | Comprehensive review. BP, breast awareness, bleeding assessment. Discuss benefits vs risks. | No arbitrary time limit on HRT (NICE NG23). Annual review of benefits and risks. Mammography per schedule. |
References: NICE NG23: Menopause: diagnosis and management (updated 2024). NAMS 2022 Position Statement on Hormone Therapy. BMS Consensus Statement on HRT (2024). IMS Recommendations on Menopausal Hormone Therapy (2023).
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