Hormone Therapy for Menopausal Women in the Primary Care Setting

Kyleen E. Swords, MS, FNP-BC

Disclosures

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

In This Article

Management

Once MHT has been initiated, a 3-month follow-up can be considered for an in-person visit with the prescribing provider.[6,8] The patient's blood pressure and level of effective symptom relief should be assessed at all subsequent follow-up visits. If the patient reports ineffective management of symptoms, the therapy can be adjusted, and the patient should be reassessed in another 3 months. Once the MHT is reported effective in symptom relief, a prescription for the therapy can be provided for 1 year. Women using MHT should be reassessed on an annual basis to determine the relief of symptoms, the development of any contraindications, side effects of the therapy, and the necessity of continuing treatment.[5,6]

Many women stay on MHT through the transitional period from perimenopause to menopause, eventually stopping the medication after 5 years of use or by the age of 65 based on past recommendations. However, the NAMS has adapted its guidelines and now discourages the stoppage of MHT based on age or length of therapy alone.[20] On average, women experience VMSs for ~7 years; therefore, it is now recommended that women who have persistent VMSs and are satisfied on the therapy may remain on MHT regardless of age as long as the NP reassesses the overall health status of the patient and the patient understands the risks versus benefits of continuing therapy at a postmenopausal age.[20] The decision to remain on MHT should be individualized and based on shared decision making between the patient and the NP. Evidence for the most appropriate way to discontinue MHT is currently limited, and women have been successful in both tapering the therapy and abruptly discontinuing.[21]

In addition to monitoring for symptom relief, there are a few conditions that a patient and NP must recognize as potential danger signs that require immediate follow-up, but not limited to, spontaneous vaginal bleeding, breast cancer, and the development of cardiac disease. It is imperative that any changes in the patient's health status are reported to the NP, and the risk versus benefit of MHT is reassessed. If a woman on MHT experiences spontaneous vaginal bleeding (after 1 year without menstruation), the provider must assess the patient for endometrial hyperplasia and endometrial cancer. This requires a referral to a women's health provider for a pelvic ultrasound and endometrial biopsy for further assessment. Additionally, the development of breast pain, breast lumps, or breast asymmetry are all potential danger signs of breast cancer and should be assessed by a provider. A mammogram and, if indicated, a breast biopsy will help exclude a diagnosis of breast cancer. Women on combined MHT, are at a slightly increased risk for breast cancer while taking MHT, as well as for several years after the discontinuation of therapy. This risk is associated with the length of time a woman is on MHT, as well as her calculated lifetime risk of breast cancer at the time of MHT initiation.[5] At annual visits, mammogram guidelines should be reviewed, and appropriate screening should be encouraged. Finally, although MHT use has been associated with reduced risk of CVD when initiated close to menopause (ages 50–59),[6,13,22] any increase in blood pressure or the development of a blood clot, stroke, or development of a condition causing an increased risk for CVD should be further assessed by the NP. Any of these symptoms justify the discontinuation of hormone use and further appropriate evaluation.

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