Hormone Therapy for Menopausal Women in the Primary Care Setting

Kyleen E. Swords, MS, FNP-BC


Journal for Nurse Practitioners. 2017;13(8):562-569. 

In This Article

Initiation and Management of MHT


Dependent on a woman's presenting symptoms, there are 2 options for hormone therapy that an NP and a patient can choose from: local/topical therapy versus systemic therapy. In addition to being guided by the predominant menopausal symptom, the risks, benefits, and convenience of each form of therapy should be individualized and considered before MHT initiation. It is important to assess a woman's comfort level with the particular form of therapy, and the decision to start MHT should be a shared decision between the patient and the provider.[6]

Genitourinary symptoms, specifically vaginal dryness, dyspareunia, and recurrent urinary tract infections, are typically treated with a local form of MHT. Local/topical therapy is available in 3 different forms: a vaginal cream inserted into the vagina with an applicator (eg, Estrace cream [Allergan Pharmaceuticals Inc., Dublin, Ireland] and Premarin cream [Wyeth Pharmaceuticals Inc., Philadelphia, PA]), a vaginal ring inserted into the vagina for 90 days (Estring [Pharmacia & Upjohn Co., New York, NY]), or tablets inserted into the vagina (VagiFem [Novo Nordisk Health Care, Plainsboro, NJ]).[12] The purpose of topical MHT is to deliver estrogen locally, directly to the vaginal walls, to dissipate symptoms by decreasing vaginal dryness through estrogen replacement to the area. Topical therapy is very common because it is easy to use, and many women feel more comfortable using a therapy whose mechanism of action takes effect locally instead of systemically.[12]

Alternatively, systemic therapy is indicated when a woman complains of night sweats or hot flashes, both of which are VMSs that are directly related to the absence of endogenous estrogen in the body. Systemic therapy produces more of an overall effect on the body compared with local therapy; therefore, it targets symptom relief for night sweats and hot flashes. Systemic therapy comes in multiple forms: oral tablets taken on a daily basis, a transdermal patch that is changed either weekly or biweekly, a transdermal spray or gel, or a vaginal ring. Systemic MHT can also help dissipate vaginal atrophy symptoms.[12]

Because estrogen is being reintroduced or replaced in the body with systemic therapy, an important consideration in prescribing this therapy is whether or not the woman has had a hysterectomy. When a woman has had a hysterectomy, estrogen replacement in the form of MHT can be prescribed as monotherapy. However, when a woman has not had a hysterectomy, the use of systemic exogenous estrogen unopposed by progestin can put her at risk for hyperplasia of the uterine lining and increase her risk for endometrial cancer. For women who have not had a hysterectomy but still wish to use MHT because of VMSs, combined therapy of estrogen and progestin must be prescribed. Adding progestin to the regimen will reduce the risk of endometrial hyperplasia, therefore decreasing endometrial cancer risk.[19] Alternatively, according to the NAMS, women who use low-dose topical estrogen do not typically need a progestin counterpart because the dose of locally applied exogenous estrogen is low and systemic absorption is minimal.[4,12] Table 3 lists the possible medication regimens for systemic and topical MHT.

Once an appropriate therapy has been chosen, dosing should begin at the lowest possible dosage.[4] Monitoring of symptoms over time for persistence or relief allows for the appropriate titration of the dose.