Perimenopausal Care and Hormone Therapy

How I Practice Video Series
Ann L. Honebrink, MD, FACOG

HIP: Perimenopausal Care and Hormone Therapy from ACOG on Vimeo.


When a patient comes in complaining of menopausal symptoms, the first thing I do is try to get her to delineate exactly which symptoms are bothering her. After that I take a detailed history or review her history and update her medical problems paying special attention to any risk factors for cardiac disease, blood clots, liver disease, and her family history and personal risk factors for osteoporosis and breast cancer, as well as making sure she hasn’t had any recent heavy bleeding or abnormal bleeding. After that, I go over each of the symptoms with her and talk about whether I think that those symptoms are likely caused by menopause or the menopause transition or whether they might be part of the normal aging process or something else we need to look for a different diagnosis for or some of each. Particularly with some of the symptoms women feel are related to menopause, with their mood or with their libido or with their sleep, it’s sometimes hard to sort out what’s part of the normal aging process or what’s part of another problem.

After we do that, if it seems to me that her symptoms will likely be helped by hormone therapy and if she doesn’t have any contraindications, I have a discussion with her about what we know about the risks and benefits of hormone therapy, especially as it relates to a possible increase in breast cancer risk, uncertain effects on cardiovascular risk, and a possible reduction in fracture risk. However, all of those for an individual woman increase or decrease on the order of less than ten per ten thousand women per year so when we talk about an individual often those risks become less significant than when we’re talking about the whole population and I try to help her understand that and think how for her hormone therapy might be helpful. Once we’ve done that, if she decides that she would like to try hormone therapy, I set really specific goals and we write them down together for what we hope to accomplish. And usually that’s better sleep, less hot flashes, maybe better sex, and nothing that she won’t like happening.

So I have a little anticipatory guidance about bleeding that might happen and try to talk about how frequently women will have bleeding after they start hormone therapy but we’d expect it to get better over time and give her some parameters for what I’d like to hear about bleeding wise. And I also talk with her about expecting some breast tenderness if she chooses to start systemic hormone therapy. So once those decisions and goals and side effects have been discussed, the next thing I do is move on to the selection of what type of therapy is right for her. If she has a uterus and we think systemic hormone therapy is what will help her symptoms, we talk about whether transdermal or oral estrogen is right for her and whether she would like to use progesterone in a cyclic way if she has a uterus and expects bleeding or in a continuous way and hopefully not have any bleeding at least over time.

Finally, after we’ve got our goals and we’ve picked our method of treatment, we talk about follow-up. I see her back in three months to make sure that she’s not having any bad side effects, to review how she’s doing, and to make sure we’re making our goals. Then I usually meet with patients if things are going well every six months once they start hormone therapy and after they’ve felt well for a while I’ll start to inch back little by little on the dose with the goal of getting to the lowest dose they feel okay on and often over time if we pick our time right and don’t change the dose at a time that we know is going to be really stressful for the woman, we can get down to either a very low dose or no dose after a few years. And that’s how I practice.


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