Eastham Group Practice

47 Bridle Road, Bromborough, CH62 6EE | Telephone: 0151 327 1391 | cmicb-wi.gatekeeper-n85005@nhs.net

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Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) is a treatment used to relieve symptoms of the menopause. It replaces the female hormones that are at a lower level as you experience the menopause.

Oestrogen and progesterone are female hormones that play important roles in a woman’s body. Falling levels cause a range of physical and emotional symptoms, including hot flushes, mood swings and vaginal dryness.

The aim of HRT is to restore female hormone levels, which can bring relief to many women, please follow the link to NHS information  www.nhs.uk/conditions/hormone-replacement-therapy-hrt/risks/

New HRT Prescription Prepayment Certificate

HRT is a first line treatment in helping to manage symptoms of perimenopause and menopause. But it’s not always easily available. We’ve been calling for improved access to HRT and hope this new certificate will help to make it more accessible to those who may need it.

The new certificate, which can be purchased from the NHS website for a one-off payment of £19.30, will cover an unlimited number of HRT medicines for 12 months.

HRT Annual Review

Patient Details

MM slash DD slash YYYY


Height, Weight and Blood Pressure.

Are you currently taking your HRT?(Required)
If you have a uterus this must include a progesterone component eg Mirena Coil in date (5 years since insertion), Utogeston or combined HRT as advised(Required)
Have you had a Hysterectomy?(Required)
Do you have a Mirena Coil in place, that has been inserted in the last 5 years?(Required)
What is the reason for you taking HRT?(Required)
Do you have a history of Endometriosis?(Required)


What is your Smoking status?(Required)
Do you drink alcohol?

Medical History

Do you have, or have you had a blood clot? (Sometimes called a Deep Vein Thrombosis or Pulmonary Embolus)(Required)
Do you have, or have you had breast cancer?(Required)
Do you suffer with Migraines?(Required)
Do you have periods or bleeding with your HRT?(Required)
Have you had any unexpected bleeding since starting HRT including after Intercourse?(Required)

Family History

Do you have any family history of heart disease or stroke under the age of 45 years?(Required)
Do you have any family history of blood clots (sometimes called a deep vein thrombosis or pulmonary embolus)?(Required)
Do you have any family history of breast cancer under the age of 50?(Required)

General Information

To safely prescribe HRT, we need to ensure that you are aware of the risks that may be present with HRT. Please indicate that you are happy to proceed with HRT despite these risks by answering the following questions(Required)
HRT is not always necessary, and many women find that they can reduce menopausal symptoms through regular exercise; by keeping their weight in a healthy range for their height and reducing alcohol and caffeine. Do you wish to proceed with HRT despite this?(Required)
Do you understand that rarely oral oestrogen as part of HRT can cause a clot and the symptoms/signs of a blood clot are calf pain and swelling, sharp chest pains, shortness of breath and coughing up blood and will seek urgent medical attention if these symptoms occur: (through the skin oestrogen does not have this risk)(Required)
Do you understand that you should tell a healthcare professional, that you are on HRT (if you take oral oestrogen) if you need to have an operation or have a period of prolonged immobilisation e.g. leg in plaster?(Required)
Do you understand that irregular vaginal bleeding on HRT should be reported to a clinician?(Required)

Screening History

Are you up to date with your smears?(Required)
If you are over 50, are you up to date with your breast screening? Breast screening is normally every 3 years for ages 50-70 years(Required)
Do you have any new breast symptoms that weren’t here before eg lump, nipple discharge?(Required)
This field is for validation purposes and should be left unchanged.
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