Prescribing of Hormone Replacement Therapy (HRT)

Applies to: All prescribers within the practice (GPs)

Based on: NICE guidelines NG23 (Menopause: diagnosis and management)

https://www.nice.org.uk/guidance/ng23 

1. Purpose and Scope

This policy provides a framework for safe, evidence-based prescribing of HRT in women experiencing menopausal or perimenopausal symptoms. Guiding consistency with NICE guidelines, BMS guidelines and BNF recommendations.

2. Aims

·         Support shared decision-making about the benefits and risks of HRT.

·         Ensure HRT is prescribed at licensed doses and formulations only.

·         Encourage ongoing breast awareness and self-examination with use of HRT

·         Provide guidance for HRT use alongside other therapies (such as Mounjaro/tirzepatide) and ensure sufficient dosage of progesterone to maintain sufficient endometrial protection.

·         Promotion of regular annual HRT review and safe continuation or withdrawal.

3. Clinical Guidance Summary

 Indications of HRT

·         Relief of vasomotor symptoms (hot flushes, night sweats).

·         Prevention of osteoporosis in women <60 or within 10 years of menopause if symptomatic.

·         Urogenital symptoms associated with menopause, not relieved by local oestrogen.

·         Consideration of HRT to alleviate symptoms of depression with onset around the same time as other symptoms associated with menopause (not meeting the criteria for a diagnosis of depression)

Contraindications

·         Current, past, or suspected breast cancer.

·         Known or suspected oestrogen-dependent cancer.

·         Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism).  (note VTE risk is not increased with transdermal HRT or utrogestan)

·         Undiagnosed vaginal bleeding.

·         Untreated endometrial hyperplasia 

·         Personal history of coronary heart disease or stroke; ensure discussion with specialist advice.

·         Acute or active liver disease.

·         Pregnancy.

·         Thrombophilic disorder.

4. Prescribing Principles

Shared decision-making

Discuss benefits, risks, route options, duration, and review schedule.

Document decision and discussion in the patient record.

Licensed formulations and doses

Prescribe only licensed HRT preparations as listed in the BNF and NICE CKS. Ensure licensed doses for all components.

Only licensed doses will be prescribed by Lightwater Surgery

Patients advised to take only prescriptions provided by GP, not advised to take multiple prescriptions from multiple sources.

Privately sourced advice recommending any dosages above given licensed doses of off-license will not be prescribed or supplied by GP (note indicated high hoses indicated as off-license)

If supplementary private HRT prescriptions are obtained, NHS-GP prescriptions for HRT will be stopped to avoid breach in compliance to prescribing and licensing guidance.

 HRT and Incretin-based therapies, notably GLP-1 eg. Mounjaro (tirzepatide)/ Ozempic & Wegovy (semaglutide)

·         No absolute contraindication to concurrent use.

·         Mounjaro delays gastric emptying, which may reduce absorption of oral HRT.

·         Preference for transdermal HRT formulations in patients using incretin-based semaglutide/tirzepetide

·         From a pharmacokinetic perspective, tirzepatide might impact the absorption of progestogen

·         Oral progestogen/progesterone: Consider changing to LNG-IUD/increase dose of progestogen/progesterone at initiation for 4 weeks and maintain higher dose for 4 weeks after any dose increment

·         Monitor symptoms after initiation or dose increases.

·         Review after 3 months.

5. Monitoring and Review

Parameter	Frequency	Action
Symptom review	At 3 months, then annually	Assess control, adverse effects
Blood pressure, BMI	Annually	Manage cardiovascular risk
Breast awareness	Ongoing	Reinforce self-check education
Vaginal bleeding	As required	Investigate abnormal bleeding promptly
Therapy appropriateness	Annually	Consider dose taper or continuation per patient preference at annual review

Avoid routine blood test to check oestrogen levels unless sufficient/maximum HRT dose and still symptomatic to establish if absorbing oestrogen. 

6. Breast Awareness and Self-Check

Provide information on breast self-awareness at initiation and review. Advise patients to be familiar with their normal breast appearance, report new lumps or changes, and attend NHS breast screening when eligible. Record that breast awareness advice has been given.

7. Documentation

Record all HRT discussions, benefits/risks, and patient decisions

Include HRT type, dose, route, review date, and any interaction considerations (e.g., Mounjaro).

8. Safety and Reporting

Encourage patients to report adverse effects or concerns promptly. Report suspected adverse reactions. Check NICE/MHRA updates for HRT safety notices.

Conduct annual HRT prescribing audits to ensure licensed use, breast awareness advice, and follow-up compliance.