Menopausal Hormone Therapy (MHT) is the most effective treatment for vasomotor and genitourinary symptoms of menopause. For most women, it can be safely prescribed in primary care when the formulation, dose, and route are tailored to the individual.

However, some presentations require additional caution or specialist input to ensure safety — particularly in women with complex medical histories, hormone-sensitive conditions, or diagnostic uncertainty.

This summary outlines key situations where GPs should consider referral/shared care with an endocrinologist, gynaecologist, or oncologist for advice or shared management.

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⚕️ When to Refer or Seek Specialist Advice

1. History of Hormone-Dependent Malignancy

Specialist review is recommended before prescribing systemic MHT in women with a history of:

• Breast cancer, especially oestrogen or progesterone receptor–positive disease.
• Endometrial carcinoma, particularly Type I (endometrioid) adenocarcinoma.
• Uterine sarcomas, including leiomyosarcoma and low-grade endometrial stromal sarcoma.
• Granulosa cell tumour (oestrogen-producing).
• Endometrioid or low-grade serous ovarian carcinoma, or serous borderline tumours.
• Adenocarcinomas of the cervix or vulva with known hormone receptor expression.

💡 Vaginal oestrogen for genitourinary symptoms is often acceptable under oncology supervision due to minimal systemic absorption.

2. Endometriosis (With or Without Prior Malignancy)

Oestrogen can stimulate residual endometriotic tissue.

• Use continuous combined oestrogen-progestin therapy or a levonorgestrel IUS for protection.
• Refer if there is deep infiltrating disease, recurrence after surgical menopause, or pelvic pain flare following MHT initiation.

3. High Thrombotic or Cardiovascular Risk

Specialist advice is warranted for women with:

• Previous venous thromboembolism (VTE) or known thrombophilia.
• Stroke, ischaemic heart disease, or multiple vascular risk factors (hypertension, diabetes, smoking, obesity).
• Migraine with aura or new neurological symptoms on MHT.

💡 Transdermal oestradiol is the preferred route for women with cardiovascular risk factors, as it avoids hepatic first-pass metabolism and has a lower VTE risk.

4. Liver Disease or Gallbladder Dysfunction

Avoid oral oestrogen in active hepatic disease or unexplained cholestasis.

• Transdermal therapy can be considered once liver function has normalised.
• Refer if there is persistent hepatic enzyme elevation, autoimmune hepatitis, or significant fatty liver disease.

5. Elevated Breast Cancer Risk (Without Personal History)

Refer or discuss with a specialist if there is:

• A strong family history or BRCA mutation.
• Atypical hyperplasia or LCIS on previous histology.
• Uncertainty about the safest hormonal or non-hormonal approach (note there are a variety of non-hormonal approaches available. Read our blog article on this here

6. Uncertain Diagnosis or Early Menopause

Specialist review is appropriate when:

• Menopausal status is unclear (e.g., perimenopause with ongoing cycles or recent contraceptive use).
• Premature ovarian insufficiency (POI) or surgical menopause is suspected.
• Unexpectedly high or low hormone levels are found.
• There is coexisting androgen excess, thyroid disease, or other endocrine disorder.

7. Recurrent Intolerance or Inadequate Symptom Control

If symptoms persist despite standard MHT regimens, or side effects limit adherence:

• Consider referral for reassessment of hormone levels, alternative formulations, or combined androgen therapy.
• Endocrinologists can assist with dose titration based on both symptom profile and biochemical response.

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🌿 Practical Guidance for Primary Care

• Transdermal oestrogen is the safest route for most women with vascular risk, migraine, or metabolic comorbidities.
• Unopposed oestrogen must not be used in women with an intact uterus.
• Vaginal oestrogen is safe in most cases, even with prior cancer, when systemic absorption is minimal.
• Annual review is essential to reassess risk, indication, and ongoing benefit.
• Document shared decision-making, especially when prescribing MHT in borderline or complex situations.

🧭 Key Takeaway

For most women, MHT can be safely initiated and managed in primary care.
But when the picture is complex — due to malignancy, vascular risk, endocrine disorder, or diagnostic uncertainty — early specialist involvement helps optimise both safety and outcomes.