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Recognising When to Refer When Conducting HRT Reviews

Red flag standing on a clipboard with a stethoscope on top and medication surrounding it.

Hormone Replacement Therapy (HRT) plays a pivotal role in alleviating the symptoms of menopause, making it crucial for pharmacists to ensure its safe and effective use. Inspired by our recent podcast episode, this article explores three common cases that pharmacists should be aware of.


Vaginal Bleeding


Vaginal bleeding is a significant concern for patients undergoing HRT. If vaginal bleeding is reported during a consultation, it's essential to first obtain a clear history. This includes inquiring about the nature and duration of the bleeding, and if it is related to sexual intercourse.


Following this, you should also assess the patient's adherence to their current HRT regime. This assessment should cover adherence to treatment, including timeliness of patch replacement, as deviations from the prescribed regimen can frequently result in breakthrough bleeding.


If the above has been reviewed and concerns persist, you will then need to refer the patient to a GP for a vaginal examination. Depending on the nature and duration of the bleeding, the GP may then consider additional scans.



Dryness and Soreness of the Vagina


Vaginal dryness and soreness are symptoms frequently encountered by women over 60, which may not always improve with systemic HRT. If dryness or soreness is reported, the use of topical oestrogens, including pessaries or creams, can be considered as they may provide additional relief if the underlying cause is due to oestrogen deficiency. However, this is not always the case and could be due to a dermatological cause such as Lichen Sclerosus. Therefore, pharmacists should refer patients with vaginal symptoms to their GP for a vaginal examination before any treatment is prescribed. This ensures that the patient is correctly diagnosed, and the most appropriate and safe treatment plan is followed.



Unexplained Weight Gain


Unexplained weight gain can be another reason for referral for patients undergoing HRT. This symptom may indicate hormonal imbalances or other underlying health issues that require attention. If the patient is gaining unexplained weight, pharmacists should start by documenting a detailed record of the patient's weight changes and inquire about lifestyle factors that might contribute to weight gain.


It is imperative for pharmacists to evaluate the patient's current HRT regimen to determine its potential contribution to weight gain. This evaluation requires a thorough review of the hormone types, dosages, and delivery methods being used. Hormonal imbalances can frequently cause weight fluctuations, and adjustments to the HRT regimen may be necessary. These adjustments could involve modifying the hormone types, dosages, or methods of delivery to reduce weight gain while continuing to effectively address menopausal symptoms.


Should the unexplained weight gain persist, a referral to a GP or endocrinologist may be needed for a thorough evaluation. This step allows for the possibility to uncover or exclude other potential causes of weight gain, such as thyroid disorders, metabolic syndrome, or insulin resistance.


In Summary


Recognising and acting upon certain symptoms such as vaginal bleeding, vaginal dryness, and unexplained weight gain is vital. The above are just a few cases where referral may be necessary. There are other causes for referral such as premature ovarian insufficiency under the age of 40, patients with persistent troublesome adverse effects, ongoing symptoms despite treatment, and high-risk patients requiring HRT. For a comprehensive list of all cases that require a referral, see the latest NICE guidance on menopause.


Taking a comprehensive patient history, ensuring medication adherence, and understanding when to escalate concerns for further investigation are essential for effective HRT management. By following these guidelines, pharmacists can make a significant difference in patient care, and ensure interventions are timely and appropriate for any issues that may arise.

To watch our full podcast episode with Dr Emma Woodcock, please click here.


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