Over the last year, there has been an increase in HRT requests. This may be driven in part by the Davina McCall series:

The BMS has made a useful response to this. Awareness of the menopause is important, as well as HRT which can help so many people (probably more than currently use it). In that sense, the program has been helpful. However, the program has seemed to leave the impression that HRT is a wonder fix for everyone.

In balancing the risks and benefits in 2022, the following trends have become apparent, summarised nicely by the BMS:

• The CV risks are probably less than we used to think. If HRT is started before 60 years of age and within 10 years of menopause, current thinking is that there is no increased CV risk. There may be a golden window where starting HRT early and before 60 years is in fact cardioprotective.
• Bioidentical hormones can refer to two different concepts. The first is the actual hormones themselves that are found naturally in the body – estrone E1, estradiol E2 and estriol E3, plus progesterone. These are in contrast to say ethinyloestradiol which is not found in the body (and is often found in the COCP for example). We can prescribe bioidentical HRT already in this sense, such as utrogrestan.
• The second concept is the combination of these hormones. There are regulated ratios and unregulated, “customised” ratios that are purportedly based on things like saliva/blood samples. The unregulated versions aren’t shown to be better and are often marketed by private companies.
• The cancer risks are often helpfully contextualised by comparing to other risks e.g. the extra 4 per 1000 cases of breast cancer over 5 years for women between 50-59 if they take combined HRT is less than the extra 5 per 1000 cases if a woman drinks 2+ units/ETOH a day, or the extra 24 cases per 1000 if a woman’s BMI is greater than 30.

These have therefore become my go-to options for combined, obviously balanced with what she wants/her perspective, and based on whether she needs unopposed/combined, sequential or continuous etc:

• Rolls-Royce winner if contraception wanted -> Mirena coil and topical estrogen. This has all the benefits with minimal risks (excess VTE risk with topical estrogen thought to be zero, provides contraception).
• Alternative if contraception not needed/coil not wanted -> Topical estrogen and microinoised progesterone -> microionised progesterone may not increase the risk of breast cancer, though this is still needing further investigation after the first 5 years -> https://associationofbreastsurgery.org.uk/media/252011/risks-and-benefits-of-hrt-2020.pdf.
• Otherwise, if no topical options wanted and only oral wanted, then do this.

One go-to option if contraception is wanted alongside HRT, and Mirena isn’t suitable, is to add a POP.