Menopausal Concerns and Hormone Therapy Overview
Menopausal hormone therapy (MHT or still referred to as hormone replacement therapy [HRT] by some) is an issue where standards have changed as additional research data has evolved. The Women’s Health Initiative (WHI) results, published in 2002, turned the conventional wisdom on this issue upside down. The number of women taking hormones for menopausal symptoms plummeted after the initial release of the WHI results, and current research suggests that use of MHT remains lower than 2002 levels but is higher than the drop which occurred immediately after publication of the WHI data.
Although caution still exists on this topic, it is imperative that triage nurses educate themselves as to current research and supporting clinical recommendations that exist. For example, there is now strong clinical evidence that most women’s vasomotor symptoms will typically occur between the ages of 45 and 55 years, generally last 5 years or less, and that by age 60 years, the vasomotor symptoms of menopause will usually have resolved. Additionally, for those women who enter menopause (either naturally or as a result of surgery or other medical intervention) before the mean age of 51 years, most will become asymptomatic within 10 years. Some women will want to use some form of therapy until their vasomotor symptoms have resolved.
MHT refers to the prescribing of estrogen, progesterone, or a combination of both. The hormones may be given continuously, meaning that the same doses of both estrogen and progesterone are used daily. The desired result with this regimen is amenorrhea. They may also be used in a cyclic fashion, with estrogen given throughout the month, and progesterone used to counteract the buildup of the uterine lining by taking it for part of the cycle. This results in a withdrawal bleed for most women.
The various hormones come in an array of delivery systems: pills, patches, topicals, rings, intrauterine devices (IUDs), and, rarely, injections. A patient may use one or a combination of delivery systems based on her preference or response to MHT. Other hormones are occasionally added. In traditionally manufactured MHT, the only hormone currently excluded is testosterone. Some compounded products have been under scrutiny by the U.S. Food and Drug Administration (FDA). They are beyond the scope of this text but may be utilized by practitioners with whom you work.
The term “bioidentical” is somewhat misleading and often associated with more “natural” hormones. All hormones, whether they are compounded or not, are manufactured from synthetic materials to mimic hormones naturally made by the body. The Endocrine Society Consensus Panel has recommended against using “custom compounded” MHTs that have not been approved by the FDA.
The most current evidence-based practice guidelines on the use of MHT have been published by the Endocrine Society (2015) (see https://academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2015-2236). These are updated regularly as newer research evidence develops, and they are an excellent source of information. The Endocrine Society guidelines emphasize the need to individualize treatment after accounting for a woman’s baseline cardiovascular risk, breast cancer risk, age, length of time since becoming menopausal, and personal preferences. The consensus panel has determined that MHT is the most effective treatment for relief of vasomotor and other symptoms that are experienced in menopause. Consensus data on the use of MHT shows some benefits in terms of reduction of anxiety and depressive symptoms, arthralgias, bone loss and fracture, diabetes, and dementia. However, all of these benefits are typically less than with utilization of other therapies, such as selective serotonin reuptake inhibitors (SSRIs) for anxiety and depressive symptoms; bisphosphonates for bone loss and fracture; and metformin, oral hypoglycemics, insulin, and other medications for diabetes.
Data have become increasingly strong that MHT is generally safe to use if a woman is less than 60 years of age or is less than 10 years postmenopausal; is experiencing vasomotor symptoms that adversely affect her life; and does not have breast cancer, thromboembolic, or cardiovascular risk factors. Such low-risk patients are usually prescribed estrogen therapy (ET) if they do not have a uterus or estrogen plus a progestin therapy (EPT) if they still have a uterus. ET may be given orally, via a transdermal patch, by vaginal ring, or by means of a transdermal cream or gel. Progestin may be delivered orally, by use of a cream or gel, or by means of an IUD. Transdermal rings, gels, sprays, patches, and IUDs avoid the “first pass effect” that occurs when patients use oral medications, so the amount of hormone that is needed for symptom reduction is lower. For this reason, many providers will prescribe an ET or EPT that is not delivered orally. Again, some patients prefer oral medications, and this is certainly a factor that may dictate the type of therapy that is selected.
For those women at risk for or who have cardiovascular disease, thromboembolic events, or breast cancer, current recommendations suggest use of a nonhormonal therapy (such as gabapentin, pregabalin, SSRIs, serotonin-norepinephrine reuptake inhibitors [SNRIs], or clonidine).
All women should be counseled on environmental measures that may greatly improve their vasomotor symptoms. Such interventions include dressing in layers, sleeping in athletic clothing that wicks away moisture, turning down the thermostat, reducing obesity, and avoiding alcohol and spicy foods. Unfortunately, evidence on the benefits of over-the-counter therapies is inconsistent. Benefits of black cohosh, red clover, vitamin E, omega-3 fatty acids, and other botanicals are not yet convincing either way. Similarly, some women have reported that acupuncture and yoga therapies are helpful, but the data is inconclusive in this regard as well.
In the case of vaginal or urogenital symptoms, local therapy should be considered first (e.g., creams, suppositories, rings). An oral therapy has also been approved for the treatment of vaginal dryness.
Some other important information for patients to know is that although MHT is not thought to cause breast cancer, it may promote the growth of breast cancers that are already present. The risk is higher for women who use EPT. In the WHI study, women who took estrogen alone did not show an increased risk of breast cancer, whereas women in the trial who took both estrogen and progesterone showed a slight increased risk.
In summary, there is perhaps no more controversial topic in women’s health than the subject of MHT. Many women want to take MHT due to symptoms and sometimes for “health reasons” that are not totally substantiated. As educators, the goal of all providers is to help the women they serve make informed choices. They need to recognize that “quality of life” is also an important measure of health which may conflict with conventional wisdom. Consequently, all providers need to be as factual and nonjudgmental as possible in advising patients on this controversial topic.
» BASIC TRIAGE ASSESSMENT FORM FOR HORMONE THERAPY
What hormone regimen are you following?
Estrogen (ET) only (confirm that patient has had a hysterectomy or has provider approval)
Estrogen and progesterone (EPT)
How are you taking your estrogen?
Day 1 to day 25
Every day
Other__________________________________________________________________________
What dose and what brand of estrogen are you taking? Brand ____________________ Dose ____________________________________________________________________________________
Oral product __________________________________________________________________
Transdermal: patch/cream/gel/lotion _______________________________
Combined estrogen and progesterone oral _______________________________________
Combined estrogen and progesterone patch ______________________________________
Other__________________________________________________________________________
How are you taking your progesterone?
Cyclically, days ____________________ of the month (e.g., days 1 to 12; days 15 to 25)
Continuously (every day)
Other __________________________________________________________________________
I do not need a progesterone/progestin because I have had a hysterectomy. (Go to Question 6.)
What dose and what brand of progesterone are you taking? Brand _________________ Dose _____________________________________________________________________________________
Oral product ___________________________________________________________________
Combined estrogen and progesterone oral ________________________________________
Combined estrogen and progesterone patch _______________________________________
Other __________________________________________________________________________
Are you taking any other hormones?
Androgens ______________________________________________________________________
Thyroid ________________________________________________________________________
Other __________________________________________________________________________
Are you taking any other medications?
Drug ______________________ Dose ______________________ Duration ______________________
Abdominal Pain and Hormone Therapy
» Key Questions
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STEP A: Severe Pain
The patient may have an acute abdominal problem or vascular condition; immediate referral to a primary care provider is indicated. The patient or her agent should call 911. The patient should not drive herself.
STEP B: Mild/Moderate Pain
The patient may have an acute abdominal condition and needs evaluation, but the disease process may be milder. Refer the patient to a primary care provider within 24 hours.
STEP C: Nausea, Vomiting, Diarrhea, or Fever
The patient may have gastroenteritis. If she has no other complications, the condition may be managed with the patient at home (see Patient Education).
A referral to the patient’s primary care provider or closest emergency room (ER) is appropriate when:
Evolving appendicitis is possible; instruct the patient to call back if she experiences:
increasing fever,
pain localizing in the right lower quadrant, or
symptoms not resolving within 12 to 24 hours.
Another disease condition is present (cardiovascular, pregnancy, diabetes, cancer, HIV).
The patient is very elderly and:
unable to communicate,
you are unable to adequately assess the patient’s condition on the telephone, or
the patient is living alone.
Signs of significant dehydration are evident.
The patient is unable to keep down any fluids (not even sips of water).
The patient has not voided in the last 8 hours.
The patient reports dizziness.
» Patient Education
The patient with gastroenteritis symptoms should be instructed to modify her diet for the next 24 to 48 hours. She should:
avoid milk and milk products,
slowly rehydrate with sips of water (two sips every 5 to 10 minutes), and
begin the BRAT (bananas, rice, applesauce, toast) diet after she has tolerated clear liquids.
Diarrhea often is the last symptom to resolve. Reassure the patient that this symptom may persist for several days after nausea and vomiting subside.
The patient should call back if:
symptoms do not begin to resolve within 1 to 2 days,
symptoms increase in intensity (more vomiting/nausea),
or fever develops.
Acne and Hormone Therapy
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STEP A: Recent Start of Menopausal Hormone Therapy
Skin changes consistent with mild acne may occur at initiation or restart of MHT. They may occur, rarely, at a later time in use.
Reassure the patient that this is a transient side effect.
Refer to Patient Education for methods to minimize or decrease the acne.
If the acne is severe or unresponsive to usual treatments, refer the patient to a dermatologist.
STEP B: Change in Skin Care Practices
The patient may have come into contact with an allergenic agent, and this could be dermatitis.
Instruct the patient to stop using the offending agent.
For severe reactions, the patient should be referred to a provider within 24 to 48 hours.
If the patient experiences no improvement in 7 days, she should see a care provider.
STEP C: Facial Redness
This may be rosacea, an acneform disorder in older adults characterized by vascular dilatation of the central face.
The condition is common in women older than 30 years.
It is more common in fair-complected women of Northern European descent.
The condition is characterized by a “rosy cheek” appearance.
Rosacea commonly requires topical antibiotic therapy.
Refer the patient to a dermatologist or her primary care provider within 2 to 4 weeks.
STEP D: Butterfly Pattern
This may be a skin change associated with systemic lupus erythematosus, a systemic immune system condition.
Confirmation of this diagnosis is difficult.
Skin signs are “classic” but often are absent.
Early diagnosis is helpful, so skin signs that are apparent assist in the prompt recognition of the disease.
Refer the patient to her primary care provider within 7 days.
STEP E: ABCD Lesion
This could be skin cancer.
Refer the patient to a primary care provider or dermatologist within 7 days.
» Patient Education
Instruct the patient in methods to decrease mild to moderate acne.
Wash affected areas twice a day with a washcloth and noncreamy soap.
Consider using cleansers such as Cetaphil lotion or benzoyl peroxide 10% acne wash.
Avoid picking at lesions.
Avoid oil-based cosmetics and facial creams such as Vaseline, Oil of Olay, or baby oil.
For dryness, may use Moisturel or Nutraderm.
Amenorrhea, Abnormal Bleeding, and Adjustment to Menopausal Hormone Therapy
» Key Questions
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STEP A: Bleeding After Hysterectomy
Women who have had a hysterectomy are not expected to bleed! Reassure the patient and tell her to report any vaginal bleeding immediately.
If bleeding occurs, see in 24 to 48 hours.
STEP B: Abnormal Bleeding
If the patient has not had a hysterectomy, she is at risk for endometrial hyperplasia and should be scheduled for endometrial evaluation within 72 hours.
Patients who do not tolerate progesterone may be routinely followed up by other diagnostic means for potential hyperplasia.
STEP C: Continuous Combined Hormone Replacement Therapy
Amenorrhea is a desired side effect of continuous dose MHT but may take months to be established.
Reassure the patient that amenorrhea is normal with continuous MHT.
If the patient remains anxious about this side effect, refer her to her obstetrics and gynecology (OB/GYN) care provider.
Break through bleeding may occur with continuous combined use for 6 to 9 months.
STEP D: Cyclic Therapy
After several years of cyclic therapy, it is not uncommon for periods to stop completely. However, periods do not usually stop suddenly. Amenorrhea is normal for some women using cyclic MHT, even at the time of initial administration. These women usually have a plan with their provider for occasional evaluation for endometrial hyperplasia.
Reassure the patient.
If the patient routinely has had absence of withdrawal bleeding and has not spoken with her provider about this, have her speak with her provider about the advisability of routine screening for endometrial hyperplasia.
If pregnancy is a possibility, perform a urine pregnancy test. Do not forget that “recently menopausal” women can become pregnant. Menopause has been misdiagnosed many times.
» Patient Education
Make certain the patient understands the expectations of episodes of bleeding and amenorrhea with her particular method of MHT. There are many forms of potential therapy, and patients are easily confused.
If there is any question about the patient’s regimen, refer her to the provider who is prescribing her MHT.
Bleeding/Spotting and Menopausal Hormone Therapy
» Key Questions
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STEP A: Hysterectomy
If the patient has had a hysterectomy, bleeding should be evaluated in 3 to 5 days.
The bleeding likely is coming from the vagina.
Patients may confuse rectal bleeding on underwear or tissue with vaginal bleeding.
STEP B: No Hysterectomy
If the patient has not had a hysterectomy, she is at risk for endometrial hyperplasia and should be scheduled for endometrial evaluation within 72 hours.
Patients who do not tolerate progesterone may be routinely followed up for potential hyperplasia.
STEP C: Cyclic Therapy
If the patient is taking cyclic EPT, and her bleeding is out of phase, initiate the Basic Triage Assessment for Hormone Therapy.
If the patient is taking the cyclic dose correctly and has been taking it for at least 6 to 9 months without problems, she should be scheduled for a clinical evaluation within 2 weeks.
If patient has been taking the cyclic dose correctly for 6 to 9 months and the problem has persisted longer than one cycle, she should be evaluated within 3 to 5 days.
If the patient is not taking the cyclic dosage correctly, instruct her on the proper dosage and have her call back if the problem persists beyond her next cycle.
If you can’t figure out how she’s taking the cyclic dosage or how it was prescribed, have her contact the prescriber within 24 to 48 hours.
STEP D: Continuous Dose Hormone Therapy
If the patient is taking continuous dose MHT and is bleeding erratically, initiate the Basic Triage Assessment Form for Hormone Therapy.
If the patient has been taking the dosage correctly for less than 6 to 9 months, explain that the bleeding/spotting can be expected. If it continues two more cycles, she should see her care provider for clinical evaluation.
If the patient has been taking the dosage correctly for longer than 6 to 9 months, she should be seen for clinical evaluation in 3 to 5 days.
STEP E: Other Forms of Hormones
The patient is taking another form of hormone (such as added testosterone, injectable hormones, hormonal implants, or topical hormones).
Refer the patient to the prescriber within 24 to 48 hours unless specific protocols exist within your facility for other hormone preparations.
» Patient Education
It is important for patients to understand how common bleeding/spotting can be during the first several months of continuous, combined MHT.
A certain percentage of women do not have withdrawal bleeding from a progestin. Those women need to establish a plan with their provider for being evaluated for hyperplasia, just as the woman with an intact uterus who elects not to take a progestin with estrogen needs a concrete plan with her provider.
Bone Health
Osteoporosis really has no clinical symptoms until it is far advanced. Many women with aching joints or back pain may assume they have (at a minimum) osteopenia or fullblown osteoporosis. Bone health measures to prevent osteoporosis and its complications need to begin much earlier than menopause and should be an ongoing conversation in women’s health.
» Key Questions
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» Actions
STEP A: Promoting Bone Health
Lifestyle Measures
Adequate Calcium/Vitamin D: Women who are taking approximately 1200 mg of calcium/day through their diet do not need calcium supplements. While there is some controversy over the value of supplementation, most providers continue to recommend it if there are not contraindications. Those women with low calcium intake should generally take 500 to 100 mg/day of calcium, two doses at mealtime. Women should also take 800 IU of vitamin D daily. If the vitamin D levels that are monitored by blood testing are low, the patient may be instructed to take a higher level of vitamin D. However, because vitamin D is a fat-soluble vitamin, patients
want to avoid taking too much. Typically, patients with a vitamin D level below 30 mg/dL are advised to take 4000 IU of vitamin D per day, but recommendations vary. In our practice, we advise patients to take:
want to avoid taking too much. Typically, patients with a vitamin D level below 30 mg/dL are advised to take 4000 IU of vitamin D per day, but recommendations vary. In our practice, we advise patients to take:
Exercise: Women should perform weight-bearing exercise (walking, running, golf, tennis, aerobics, etc.) for at least 30 minutes three times per week. There is no strong evidence that high-intensity exercise, such as running, produces greater benefits compared to lower intensity exercise, such as walking.
Diet: Most practices recommend maintaining a normal diet. However, if the patient has celiac disease, a gluten-free diet may improve bone density.
Smoking: Smoking one pack per day during adulthood is associated with a 5% to 10% loss in bone density. For many health reasons, it is recommended that women who smoke quit smoking.
Pharmacologic Therapy
The National Osteoporosis Foundation and several experts recommend medication for women who have T scores between -1.0 and -2.5 if they are high risk, meaning they have a fracture index (FRAX) of 3% or higher or their 10-year probability of major bone fractures is 20% or more. It is recommended that all women who have osteoporosis (a T score of -2.5 or greater) be assessed for medication therapy.
Prior to starting a medication for treatment of bone loss providers usually check the patient’s serum calcium level and 25-hydroxyvitamin D level checked. If the patient’s vitamin D or calcium levels are low, a supplement may be ordered.
STEP B: Bone Density Testing (DEXA)
A DEXA scan is an x-ray study that is used to assess a woman’s bone density. The “T score” compares the patient’s bones to women who are 35 years of age and younger. The “Z score” compares her bones to women who are her age and ethnicity. The more positive the T or Z score, the more dense her bones are and the more normal her results. Most providers use the “T score” to determine if any special intervention is warranted. Women who have a T score between -1.0 and -2.5 are classified as having OSTEOPENIA. Women who have a T score more than -2.5 are diagnosed as having OSTEOPOROSIS. Based on the test results, inform the patient if she has OSTEOPENIA or OSTEOPOROSIS.
Some bone density reports also give a FRAX score, which estimates a 10-year probability of a hip fracture or combined major bone fracture of 3.0% or 20%.
Patients who have an abnormal T score, FRAX score, vitamin D, or calcium level should be referred to a provider for further management.
This step should include an explanation of the patient’s recent test results.
As a telephone triage nurse, you will need to establish to what lengths your practice providers expect the triage staff to explain these results. If you do not feel qualified to explain the following results, it is important to receive additional training or refer the patient back to her provider.
The example in the following text shows the usual information reported on a DEXA report:
The bone density test that you had done was as follows (fill in the specific patient data):
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FRAX: _______________________________________________________________________________________________
Breast Pain and Hormone Therapy
» Key Questions
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