Explaining HRT

Communication Skills

Author – Dr Kalyani Shinkar  Editor – Dr Kalyani Shinkar

Last updated 05/03/25

Table of Contents

Introduction

Hormone replacement therapy (HRT) forms an important part of managing perimenopause and menopause. Explaining the indications for HRT, along with its benefits and side effects in an OSCE setting requires comprehensive understanding of the topic and effective communication skills. This article provides a structured guide to discussing a diagnosis of menopause and covers essential aspects of HRT.

Example OSCE Candidate Instructions

You are a junior doctor in a GP clinic. Mrs Elaine Smith is a 52-year-old woman who has come to discuss hormone replacement therapy (HRT) as a treatment option for her menopausal symptoms.

Please take a focused history and answer any questions she may have about HRT.

Introduction and History

  1. Introduce yourself, confirm patient details, and gain consent to speak to the patient.
  2. Explain the purpose of the consultation
    • “I understand that you’ve recently started the menopause and would like to discuss HRT to help you decide whether it’s the right option for you”.
  3. Take a focused history to assess whether HRT is suitable for this patient and, if so, which type of HRT is most suitable
    • Menopausal Symptoms:
      • “Have you had any of the following symptoms?”:
        • Vasomotor – night sweats, hot flushes
        • Cognitive – mood swings, depression, difficulty concentrating
        • Urogenital – dyspareunia, vaginal dryness, low libido
        • Others – palpitations, tremor
      • Onset and duration: “How long have you had these symptoms for?”
    • Menstrual History:
      • “When was your last period?” (to confirm a diagnosis of menopause or perimenopause)
      • Ascertain whether the patient has any undiagnosed vaginal bleeding, a contraindication to starting HRT:
        • “Have you had any vaginal bleeding since your last period (if menopausal)/in between your periods (if perimenopausal)?”
        • “Have you had any vaginal bleeding after sex?”
    • Contraception
      • “Are you currently using any contraception? If so, what contraceptive are you using?” (because HRT does not provide contraception and patients may need to use contraception alongside HRT)
    • Past Medical History:
      • “Do you have any conditions that you’ve been diagnosed with?”
      • “Any history of blood clots, breast cancer, endometrial cancer, or stroke?”
      • “Have you ever had any surgeries, including a hysterectomy?”
    • Drug History:
      • “Are you on any medications?”
      • “Do you have any allergies?”
    • Family History
      • “Any family history of blood clots, breast cancer, endometrial cancer, or stroke?”

Explain the Diagnosis

  • “Menopause is a natural phase in a woman’s life. It occurs when your periods stop completely, typically between the ages of 45 and 55 but can occur earlier”.
  • “Menopause happens because your ovaries stop producing the hormones oestrogen and progesterone”.
  • “These hormonal changes can cause a variety of symptoms, such as hot flushes, night sweats, mood changes, sleep problems and low libido. Some women may also experience vaginal dryness and discomfort during sex. These symptoms are a normal part of menopause, and many women experience them. However, every person is different, and the severity and duration of symptoms can vary from person to person”.

Discuss HRT

  • “There are a few ways to help manage symptoms, such as lifestyle changes, non-hormonal medications, and HRT. I understand you want to discuss HRT in particular”.
  • “HRT stands for hormone replacement therapy. It refers to a group of hormonal therapies that work to replace the low levels of hormones that occur because of menopause”.
  • “There are different types of HRT depending on which hormones they contain and how they are taken. For instance, some HRTs contain oestrogen only, whilst others contain both oestrogen and progesterone. There are also different ways in which you can HRT, the most common way being tablets. Other ways include skin patches, gels, and implants like the Mirena coil. It’s therefore important we find a type of HRT that works best for you”.
  • “I would like to now discuss the benefits and risks of taking HRT so that hopefully you’ll have enough information to make an informed decision”.
  • Benefits: “There are many benefits to starting HRT. By replacing hormones like oestrogen, this can help to alleviate the menopausal symptoms you’re experiencing. It can also reduce your risk of developing conditions that are associated with low levels of oestrogen, including osteoporosis and heart disease”.
  • Risks:
    • “However, HRT is not suitable for everyone, as there are risks associated with taking it. The risks are generally greater the older you are and the longer you take HRT for”.
    • Breast Cancer – “There is a small increased risk of developing breast cancer from combined HRT and little/no increased risk from oestrogen-only HRT. Despite there being a small increased risk of breast cancer with combined HRT, this increased risk is still low (there are around 5 extra cases of breast cancer in every 1,000 women who take combined HRT for 5 years). The risk is also less compared to other risk factors for breast cancer, such as being overweight. After stopping combined HRT, the risk of breast cancer decreases; however, there is a still a small increase in risk that lasts for more than 10 years in ex-HRT users compared with women who have never used HRT”.
    • Endometrial Cancer – “There is an increased risk of developing endometrial cancer with oestrogen-only HRT.” There is no increased risk of endometrial cancer with combined HRT.
    • VTE – “HRT in the tablet form increases the risk of developing blood clots in the legs and lungs (by 2- to 3-fold), but the overall risk is still low. The risk also depends on individual factors, such as your age, weight, and if you have had blood clots in the past. We can reduce the risk of blood clots by giving HRT in the form of a patch instead of tablets”.
    • Ischaemic Stroke – “HRT in the tablet form also increases the risk of stroke. If you have other risk factors for stroke, we may consider prescribing HRT in the form of a patch instead of tablets, as HRT that’s given via a patch does not carry an increased risk of stroke”.
  • Safety Netting: “If you do decide to take HRT, we advise you to check your breasts regularly and seek urgent medical advice if you experience any leg pain or swelling, shortness of breath, chest pain, or signs of a stroke”.
  • Side Effects:
    • “Like any medicine, HRT can cause side effects. But it’s common to have no side effects or only mild ones”.
    • Side effects of oestrogen: headaches, breast pain, nausea, mood changes, leg cramps, mild rash or itching, diarrhoea and hair loss.
    • Side effects of progesterone: headaches, breast pain, nausea, mood changes, mild rash or itching, diarrhoea, fatigue, dizziness and acne.
    • “If you do experience any side effects, these usually go after a few weeks. We advise you to carry on with your treatment for at least 3 months if possible. If you have severe side effects or they continue for longer than 3 months, please contact us and we can consider changing your dose or changing the type of HRT you’re taking e.g. switching from tablets to patches”.
    • “Combined HRT can also cause irregular, unscheduled or breakthrough vaginal bleeding. This is quite common in the first few months after starting HRT, but usually down settles down within 6 months and is often not a sign of anything serious. Please do let us know if you continue to experience these symptoms for longer than 6 months”.

Closing the Consultation

  • If there is time left at the end, you can summarise what you have discussed and ask if the patient has any questions. “To summarise, we have discussed the benefits, risks, and side effects of HRT. Does that all make sense? Do you have any questions or concerns about what we have discussed so far?”
  • Provide them with a leaflet or signpost them to useful resources (e.g. NHS website)
  • Arrange Follow-up: “I understand that I’ve given you a lot of information to process. You do not have to make a decision about whether or not you’d like to start HRT today. You can read more about HRT and discuss it with your family and friends to help you decide. We can arrange an appointment in the next couple of weeks to discuss this further if that works for you. Please feel free to get in touch in the meantime if you have any questions”.

General Tips & Advice

  • During your explanation, remember to ‘chunk and check’ to facilitate patient understanding
  • Provide support and reassurance throughout the discussion and encourage the patient to ask questions if they have any.

Viva Questions

·       Definition: Menopause is the point in time 12 months after a woman’s last menstrual period. It is caused by the loss of ovarian follicular function and decline in oestrogen levels. In contrast, perimenopause means “around menopause” and refers to the transitional period leading up to menopause. It is characterised by a decline in ovarian activity and fluctuating hormone levels. This means your periods do not stop but may become more irregular due to ovulation becoming more unpredictable; for instance, in some months, you may ovulate, occasionally even releasing two eggs in cycle, while in other months, no egg may be released at all. Perimenopause ends and menopause starts when you have not had a period for 12 months.

·       Timing: Menopause typically occurs between the ages of 45 and 55, with the average age being 51. In contrast, perimenopause typically begins in a woman’s 40s and can last until menopause.

·       Duration: Perimenopause can last anywhere from a few months to several years.

·       Hormonal Changes: During menopause, the ovaries stop producing oestrogen and ovulation no longer occurs, whereas during perimenopause, the levels of oestrogen and progesterone produced by the ovaries fluctuate irregularly.

·       Symptoms: Many symptoms of menopause are similar to those of perimenopause, including hot flushes, night sweats, sleep problems, mood swings and vaginal dryness. However, a key difference between the menopause and perimenopause is the status of menstrual periods. During menopause, a woman has not had her periods for the last 12 months, whereas during menopause, a woman’s periods may become more irregular, lighter, or heavier. 

Here is a useful formula that can be used to choose the correct type of HRT:

STEP 1 – Does the patient have local or systemic symptoms?

  • Local symptoms -> topical treatments e.g. topical oestrogen cream or tablets
  • Systemic symptoms -> systemic treatment

If Systemic Treatment:

STEP 2 – Do they have a uterus?

  • No uterus -> oestrogen-only HRT
  • Has uterus -> add progesterone (combined HRT)

If Combined HRT:

STEP 3 – Have they had a period in the last 12 months? 

  • Yes (perimenopausal) -> cyclical combined HRT
  • No (postmenopausal) -> continuous combined HRT

It usually takes 3-4 weeks to feel the benefits of HRT. However, it can take up to 3 months to feel the full effects. If a patient has not felt the benefits of HRT after 4-6 months, it may help to try a different type of HRT.

  • Undiagnosed vaginal bleeding
  • Current, past, or suspected breast cancer
  • Endometrial hyperplasia or cancer
  • Previous idiopathic or current VTE, unless the woman is already on anticoagulant therapy
  • Uncontrolled hypertension
  • Current or recent arterial thromboembolic disease (e.g. angina or myocardial infarction)
  • Active liver disease
  • Pregnancy
  • Porphyria cutanea tarda
  • Dubin-Johnson and Rotor syndromes
  • Taking combined HRT in women with a uterus instead of oestrogen-only HRT to reduce the risk of endometrial cancer
  • Taking HRT through patches instead of tablets decreases the risk of VTE and ischaemic stroke.

HRT contains very low levels of hormones and therefore does not work as a contraceptive. Perimenopausal may require both HRT for symptom management and contraception to prevent unintended pregnancy. In women under the age of 50, contraception is required until 2 years after their last menstrual period, or for 1 year in women over the age of 50.

  • Mirena coil – licensed for endometrial protection (for up to 5 years) and can be used as a contraception when combined with oestrogen-only HRT.
  • The progesterone-only implant, progesterone-only injectable, and progesterone-only pill can be used as a contraception alongside HRT. However, it cannot be used for endometrial protection alongside oestrogen-only HRT.
  • The combined oral contraceptive pill (COCP) should NOT be used in combination with HRT. The COCP can be used in eligible women <50 years old as an alternative to HRT for symptomatic relief. However, at the age of 50, women should be advised to switch to an alternative form of contraception.

There is no specific regime for stopping HRT; it can be either gradually reduced or stopped suddenly, based on the woman’s preference. However, it may be beneficial to gradually taper off HRT to help prevent symptoms from coming back suddenly.

  1. https://mlamedics.com/menopause-perimenopause-station/
  2. https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/
  3. https://www.mymenopausecentre.com/gp-resources/choosing-contraception-during-the-menopause-transition/

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