Overview of monitoring of systemic MHT

Regular clinical review of individuals using systemic menopausal hormone therapy (MHT) is necessary to:

ensure adequate symptom control
review comorbidities and reassess benefits and harms; see Surveillance for comorbidities
detect and manage adverse effects that may require change of MHT dose or formulation
perform periodic trials of reducing or stopping MHT.

Monitoring of MHT involves clinical review 6 to 8 weeks after starting or changing MHT, then again at 6 months. Ongoing review every 6 to 12 months is usually appropriate. See Monitoring systemic menopausal hormone therapy for a summary of the approach to monitoring MHT.

Table 1. Monitoring systemic menopausal hormone therapy
Reason for monitoring	Action
ensuring adequate menopausal symptom control	Review severity of menopausal symptoms 6 to 8 weeks after starting MHT, then again at 6 months; continue to review every 6 to 12 months. For persistent vasomotor symptoms: consider malabsorption of oral MHT, or confirm that the patient is applying the patch or gel correctly [NB1] increase estrogen dose; if this is not effective, consider other causes and the need for specialist referral review progestogen dose to ensure adequate endometrial protection if increasing the estrogen dose in continuous combined MHT.
surveillance for comorbidities	Surveillance involves: annual clinical review to assess comorbidities assessment of cardiovascular and breast cancer risk at least annually cancer screening as for general population. If a new comorbidity is detected, determine if therapy can be adjusted or MHT should be stopped.
to ensure adequate thyroxine replacement therapy in individuals with concurrent hypothyroidism [NB2]	Check serum TSH concentration 6 to 12 weeks after starting oral MHT; increase dose of thyroxine replacement therapy if required.
Note: MHT = menopausal hormone therapy; TSH = thyroid-stimulating hormone NB1: Measurement of serum estradiol concentration does not reliably assess the efficacy of oral MHT because most oral estrogen is metabolised to estrone; it should only be considered to check transdermal absorption if severe symptoms persist despite increased dose. NB2: Oral estrogen therapy may increase production of thyroxine-binding protein, which may necessitate an increased dose of thyroxine replacement therapy.