Pre-HRT Assessment and Management

Absolute Contraindications and Medical History

• Active or recent arterial thromboembolic disease, including myocardial infarction or stroke, is a contraindication to HRT, as stated by the American College of Cardiology 1
• Current blood pressure status is crucial, as hypertension is not an absolute contraindication, but transdermal estradiol is preferred over oral formulations in hypertensive women, according to the European Society of Human Reproduction and Embryology 2
• A history of coronary heart disease, myocardial infarction, or stroke is a contraindication to systemic HRT, as per the American Heart Association 1

Uterine Status and Regimen Selection

• The presence or absence of a uterus is critical for regimen selection, as women with intact uteri must receive progestin combined with estrogen to prevent endometrial hyperplasia, as recommended by the American College of Obstetricians and Gynecologists 2
• Women without a uterus can receive unopposed estrogen therapy, according to the North American Menopause Society 3

Cancer History and Risk

• A personal history of hormone-dependent cancers, such as breast cancer, is a contraindication to HRT, as stated by the National Comprehensive Cancer Network 1
• Family history of breast or uterine cancer alone is not a contraindication to HRT, but should be considered in the risk-benefit assessment, as per the Society of Gynecologic Oncology 3

Symptom and Indication Assessment

• The severity of vasomotor symptoms, such as hot flashes and night sweats, is an indication for HRT, as recommended by the Endocrine Society 2
• Genitourinary symptoms, such as vaginal dryness and dyspareunia, can be treated with HRT, according to the International Society for the Study of Women's Sexual Health 2

Laboratory and Baseline Testing

• Baseline lipid profile is essential to assess cardiovascular risk and monitor changes, as recommended by the American College of Cardiology 1
• Blood pressure measurement is a crucial baseline and monitoring parameter, according to the European Society of Hypertension 1

Patient Counseling Points to Address

• Expected benefits of HRT include relief of vasomotor symptoms, prevention of bone loss, and potential cardiovascular benefits if started early, as stated by the North American Menopause Society 2
• Risks to discuss with patients include small increased stroke risk, breast cancer risk with long-term estrogen-progestin use, and VTE risk, especially in the first 1-2 years, as recommended by the American College of Obstetricians and Gynecologists 4

Common Pitfalls to Avoid

• Failing to distinguish between systemic and topical estrogen risks can lead to inappropriate treatment, as warned by the American College of Cardiology 1
• Using oral estrogen in smokers is contraindicated, and transdermal route should be used instead, as recommended by the European Respiratory Society 3
• Prescribing unopposed estrogen to women with intact uteri dramatically increases endometrial cancer risk, as stated by the American College of Obstetricians and Gynecologists 2