When women start Hormone Replacement Therapy (HRT), it’s pretty common to experience some side effects. Sometimes these are mild, sometimes more intrusive, but for many women, given a little time, they will settle. It can also take time to know how much symptom relief you will experience when starting HRT. It’s for this reason that many doctors will arrange to review you at around three months into your HRT journey. It can be hard to tell much sooner than this whether the prescribed HRT is right for your body and what adjustments, if any, need to be made.
All doctors will have their own prescribing and reviewing habits, often defined as part of local NHS guidance. Some will issue you monthly prescriptions initially, and some will give directions allowing you to increase your dose gradually over time, but for the most part a three month review when you are just getting started is a good rule of thumb.
During a review your doctor will want to find out how you’ve been getting on. If you’ve experienced any symptom relief; what side effects you’ve experienced; if you’ve seen any changes in your bleeding pattern. If you’ve been given the option to increase your dose over time, your doctor will want to know what dose you’ve been using and also check that you’re taking the medication as prescribed.
It’s also good practice, though not essential, to have an up to date blood pressure reading as part of an HRT review. This can be taken in advance using a home blood pressure machine, or at a local pharmacy. Primarily this creates an opportunity for a midlife wellbeing check so that other long term health risk factors can be reduced while managing HRT.
Following this discussion your HRT may be adjusted, usually related to the dose, or sometimes a change in type. If things are going well, everything may be kept the same and another prescription issued.
If things are going well, with no changes to prescribed HRT, it would be usual for this medication to be placed on a repeat prescription and a plan for long term review agreed. This would usually be at six or twelve months, with the caveat that if you experience any problems then you return to your doctor sooner. Good prescribing practice and recommendations from the Medicines and Healthcare Regulatory Agency (MHRA) and General Medical Council (GMC) suggest that all medications are reviewed at a minimum of twelve month intervals.
Much the same as the three month review after starting HRT, an annual review should check on your progress and wellbeing. Your doctor will usually ask about bleeding changes; if you’re still on cyclical / sequential HRT; whether it would be right to consider moving to continuous HRT. Your doctor will also consider whether there’s been any important changes in your medical history and if these might effect HRT prescribing. Dosage adjustments may also be considered depending on your stage of menopause and age. Many doctors will also check that you’re up to date with your cervical screening and if you qualify, enquire whether you’ve taken up your breast screening invitation. A discussion about bone health may be included if there’s time and it’s relevant.
The answer to this varies depending on where and with who your review takes place. To review standard oestrogen only, or combined HRT, National Institute for Health and Care (NICE) and British Menopause Society (BMS)guidelines do not recommend blood testing, and instead the dosing is based on symptoms as well as your age. As such, an HRT review with an NHS GP would not usually require blood tests.
If you’re experiencing problems, or things aren’t going as well as expected, sometimes blood tests for hormone levels can be helpful. Menopause specialist doctors may also use blood tests to further individualise care and also monitor safety when off licence dosing is used. Women with
Premature Ovarian Insufficiency (POI) in specialist clinics are also more likely to be offered blood tests.
Testosterone is much more accurately and safely prescribed when blood tests are checked regularly. Before prescribing testosterone most doctors like to check testosterone and Sex Hormone Binding Globulin (SHBG) levels in order to calculate your Free Androgen Index (FAI). This level is repeated after three months and with each dose increase. Once a patient is on a stable dose blood levels would usually be repeated every year in advance of an annual review.
The easiest way of thinking about HRT reviews is that they are three monthly, approximately, when starting HRT or with any dosage change, and then annually thereafter. Of course, if you experience any problems or unusual bleeding, you should book to review with your doctor sooner. Many GP practices are overly busy, or simply don’t have systems in place inviting patients back for a review. Therefore, if you think you’re due a review it’s worth contacting your practice or prescribing doctor.
Dr Liz Andrew has worked as a GP for over 12 years and has developed a passion for offering women menopause care. She is an advocate for giving women the knowledge and support they need to make choices about their own bodies at a time in their lives that can feel fraught. She understands the unique and often misunderstood pressures on women which can become particularly difficult during the hormonal changes of peri menopause and thereon. She prescribes body identical HRT and encourages the use of lifestyle adjustments to actively improve wellbeing.
Dr Liz Andrew is part of the team of Menopause Specialist GPs at https://menopausecare.co.uk/
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