Angina Much controversy continues to surround the use of HRT and heart disease. Generally, it is becoming more accepted that, when used within ten years of the menopause, or under the age of 60, HRT is likely to prevent coronary heart disease. Menopausal women with angina requiring treatment for menopausal symptoms are usually offered non-hormonal therapies initially. If these are ineffective and HRT is being considered, it should be known that there may be a small increase in risk of myocardial infarction (heart attack) in the first year of use of systemic HRT in women with coronary heart disease, but different types and routes of hormone therapy will have different effects. In women with established heart disease, taking estrogen through the skin by patch or gel (transdermal), starting with a low dose, is generally safer than tablet form. Vaginal estrogens may be used safely for treatment of vaginal and bladder symptoms.
Blood clot (DVT/PE) Since HRT is associated with a small increased risk of venous thrombosis, care must be taken when considering HRT use in women with a personal, or family, history of thrombosis. Depending on the cause of the thrombosis, risks and benefits should be assessed. If HRT is to be used, preference would usually be given to the transdermal route (patch or gel). Specialist advice should be requested. Vaginal oestrogen can be used for treatment of vaginal and bladder symptoms.
Blood pressure (hypertension) if high, should be controlled prior to starting HRT. Blood pressure measurement should be repeated 3 months after starting HRT and is then usually checked at annual review. In the presence of controlled hypertension, HRT is unlikely to worsen control; some recommend using transdermal (patch or gel) HRT.
Breast cancer. A history of breast cancer is generally seen as a contraindication to the use of systemic HRT, and non-HRT therapies should be offered. Occasionally, if symptoms are severe and unresponsive to other therapies, HRT may be considered under specialist supervision. A recent trial, the HABITS trial suggested that HRT may increase the risk of recurrence of breast cancer but a study in Stockholm showed no increase and further trial results are awaited.
Diabetes. Women with type 1 diabetes are thought to be at increased risk of osteoporosis and coronary heart disease. The association between HRT use and diabetes has caused some confusion; some studies, including the Women's Health Initiative trial, showing a reduced risk of diabetes in women taking HRT, yet fairly recently HRT advice sheets advised caution when using HRT in diabetic women. Currently, HRT may be used when indicated in women with diabetes, and it is thought that either low dose oral oestrogen or transdermal (patch or gel) preparations are best. If progestogen is required, either dydrogesterone or micronised progesterone seem least likely to interfere with diabetic control, although further studies are required on ideal type and route of HRT. Recent research has shown reduced fasting glucose levels in women with diabetes taking low dose tablet combined HRT.
Endometriosis. There is a small risk of reactivation of endometriosis with HRT use and any recurrence of symptoms should be reported. If a hysterectomy has been performed for endometriosis, the choice of HRT use thereafter should be influenced by the extent of endometriosis at the time of the operation. HRT after hysterectomy usually consists of oestrogen only. However, in the presence of widespread endometriosis, oestrogen may cause stimulation of residual deposits and consideration should be given to using continuous combined (oestrogen plus progestogen) therapy, or tibolone, though little research has been done on the effect of different types and duration of therapy.
Fibroids are benign knots of muscle which grow from the muscle layer of the womb wall. They tend to shrink after the menopause but shrinkage may not occur, or they may even increase in size with HRT use. Increase is thought to occur in 25% of HRT users and mainly occurs in the first six months of therapy. There is some evidence that transdermal (patch or gel) but not tablet HRT or tibolone may stimulate fibroid growth. Fibroid size can be monitored by regular examinations and sometimes by ultrasound scans. There is some evidence that the use of the progestogen releasing intra-uterine system, Mirena, may cause fibroids to reduce in size. Mirena is often used as the progestogen part of HRT.
Gall stones. HRT has been shown to increase the risk of gall bladder disease, particularly gall stones, thought to be due to an effect on bile composition. Transdermal (patch or gel)HRT is usually recommended with a history of gall bladder disease.
High Cholesterol (Hyperlipidaemia) is not a contraindication to using HRT. Care should be taken to decide on the best type and route of HRT since the type and route determine the effect on certain lipids. For example, oral oestrogen generally increases triglyceride levels so that the transdermal route is preferred in the presence of high triglyceride levels.
Migraine is often triggered by hormonal fluctuations and therefore may occur around the time of a period. Such migraine may improve at the time of the menopause. Some women find that migraine may be triggered by the daily hormone fluctuations which can occur with oral (tablet) HRT so the transdermal (patch or gel) route is usually preferred with a history of migraine.
MS. Menopausal women with multiple sclerosis have additional risk factors for osteoporosis and fracture through reduced mobility and weight bearing exercise, low levels of vitamin D and sometimes previous steroid treatment and an increased risk of falling. Bone protective measures in the form of general advice and specific treatments should be considered. Multiple sclerosis is not a contraindication for HRT use when indicated.
Otosclerosis. This inherited condition causes progressive deafness has been shown to worsen with pregnancy and, very rarely, with the contraceptive pill but there is no evidence that HRT has such an effect.
Ovarian cancer. A history of ovarian cancer is generally not a contraindication to HRT.
Stroke (CVA) The incidence of stroke increases in women after the menopause. Although some studies have shown a protective effect from HRT, others, including the Women’s Health Initiative trial, have shown a small increase in risk of stroke in women taking HRT. It has been concluded that HRT should not be used for either primary or secondary prevention of stroke. If a woman has had a stroke and is considering treatment for menopausal symptoms, non-hormonal options should be tried first and HRT should only be considered after full discussion with a specialist.
Thyroid disease. Hyperthyroidism, due to either overactive thyroid gland or over-replacement of thyroxine in under active thyroid disease, leads to an increased risk of osteoporosis due to excess bone loss. HRT does not worsen thyroid disease and in fact may be particularly helpful because of the bone protective effect. However, patients taking thyroxine should be monitored by having thyroid function rechecked 3 months after starting HRT since the thyroxine dose may need to be adjusted. Similarly, thyroxine requirements may alter if HRT is stopped and thyroid function should be rechecked 3 months after stopping HRT
Uterine Cancer. A past history of uterine (womb) cancer would usually be considered a contraindication to HRT. However, if the cancer was of very early stage and there was a very strong indication for HRT, its use may be considered after a specialist opinion.
Varicose veins. The risk, if any from HRT use with varicose veins is a blood clot (deep vein thrombosis) in the leg. The risk of a deep vein thrombosis on HRT is an extra 2 women per 10,000 women years of use. There is conflicting evidence as to whether or not HRT use in someone with varicose veins increases the risk further. However superficial thrombophlebitis (pain in the superficial veins of the leg due to inflammation in the blood vessel) is probably a risk factor. To put it in perspective, being overweight is more of a risk factor than varicose veins alone.