Hormone Replacement Therapy Considerations

Family History and HRT

A family history of uterine cancer is not a formal contraindication to starting hormone replacement therapy (HRT) for women without a personal history of hormone-dependent cancers, according to the American College of Obstetricians and Gynecologists 1, 2, 3
The risk/benefit profile of hormone therapy is favorable for most women without personal history of hormone-dependent cancers, as stated by the National Comprehensive Cancer Network 3
There is no evidence to contraindicate the use of systemic or topical hormone therapy for women with a family history of uterine cancer, as this differs from having the cancer personally, based on guidelines from the American College of Obstetricians and Gynecologists 1, 3

Current smoking is a relative contraindication to oral HRT but not to transdermal HRT, as recommended by the National Comprehensive Cancer Network 4
Non-hormonal therapy may be considered in patients who are deemed poor candidates for hormone replacement therapy, including smokers, according to the American College of Cardiology 4

If a patient currently smokes, the American Heart Association recommends smoking cessation as part of risk minimization, and if HRT is necessary, use only transdermal estrogen preparations 1, 5
If a patient has a family history of uterine cancer but no personal history, HRT can be prescribed without specific contraindication, as stated by the American College of Obstetricians and Gynecologists 1, 3
If the patient has an intact uterus, combined estrogen-progestin therapy must be used, according to the National Comprehensive Cancer Network 3, 7

The risk of uterine cancer is primarily relevant for women with intact uteri using unopposed estrogen therapy, as noted by the American College of Obstetricians and Gynecologists 5, 4
Women with intact uteri must receive progestin along with estrogen to prevent endometrial hyperplasia, based on guidelines from the American College of Obstetricians and Gynecologists 3, 7
For women who have had a hysterectomy, unopposed estrogen therapy is appropriate, as recommended by the National Comprehensive Cancer Network 4

Regular clinical assessment is recommended for all women on HRT, according to the American College of Obstetricians and Gynecologists 6
Bone density status should be assessed and monitored, especially in smokers who are at higher risk for osteoporosis, as stated by the National Osteoporosis Foundation 1
The lowest effective dose should be used for the shortest duration needed to control symptoms, based on guidelines from the American Academy of Family Physicians 5

If the patient has additional risk factors, non-hormonal therapy should be considered, as recommended by the National Comprehensive Cancer Network 4
Selective serotonin reuptake inhibitors or norepinephrine reuptake inhibitors can be used for vasomotor symptoms when HRT is contraindicated, according to the American College of Obstetricians and Gynecologists 3
Non-pharmacological approaches such as cognitive-based therapy, yoga, and acupuncture can be considered as adjuncts, based on guidelines from the American College of Obstetricians and Gynecologists 3