Continuous combined hormone replacement therapy (HRT)

• continuous combined HRT (ccHRT) (1)
  
  
  • tablets and transdermal patches available
    
    
  • no monthly bleeds
    
    
  • indicated for postmenopausal women and women over 54 years (80% postmenopausal by then)
    
    
  • women currently on sequential HRT may consider changing to ccHRT after 1-2 years (if 50 years or over) or after 4-5 years (if under 50 years)
    
    
  • suitable as 'add-back HRT' for women on long-term gonadotrophin releasing hormone analogues treatment
    
    
  • reduced risk of endometrial cancer

A review stated (2) "..In women who are one to two years postmenopausal and wish to avoid bleeding, consider continuous combined HRT or tibolone..."

Tibolone (1):

• synthetic compound with oestrogenic, progestogenic and androgenic compounds
• no monthly bleeds
• beneficial effect on libido
• similar indications as ccHRT, including ‘add-back HRT’ for women on long term GnRH
• unlike other ccHRT may not reduce the risk of endometrial cancer
• insufficient data.Breast cancer risk comparable to oestrogen-only HRT
• ovarian cancer, venous thrombosis, and coronary heart disease risk - insufficient data
• stroke: significantly increased risk about 2.2 times from first year of treatment:
  • additional 9 cases per 1,000 age 50-59 years
  • additional 20 cases per 1,000 age 60-69 years

Notes:

• vaginal bleeding whilst on ccHRT (3,4)
  
  
  • if abnormal bleeding starts when using continuous combined HRT, in women >54 or > 1 year after their last period, within 6 months of starting treatment then initially a trial of oestrogen reduction should be attempted. If bleeding recurs then refer for routine hysteroscopy as benign pathology would be anticipated
    
    
  • if abnormal bleeding commences after 6 months treatment with continuous combined HRT or recurs after 6 months amennorhoea then refer for routine hysteroscopy as above
    
    
  • the BNF states "..continuous combined preparations or tibolone are not suitable for use in the perimenopause or within 12 months of the last menstrual period, women who use such preparations may bleed irregularly in the early stages of treatment - if bleeding continues endometrial abnormality should be ruled out and consideration given to changing to cyclical HRT.."
    
    
• HRT is not a contraceptive

Reference:

• (1) NHS Fife. The Fife formulary - Guidance on management of the menopause in primary care (Accessed 19/2/2020)
• (2) Hickey M, Elliott J, Davison SL.Hormone replacement therapy. BMJ. 2012;344:e763.
• (3) Wells M et al. Effect on endometrium of long term treatment with continuous combined oestrogenprogestogen replacement therapy:follow up study BMJ 2002; 325:239- 2
• (4) Bradford Hospitals NHS Trust (accessed 30/5/13). Guidelines for hysteroscopic investigation of abnormal uterine bleeding in women using HRT.
• (5) BNF 6.4.1.1