Continuous Combined HRT

In an effort to eliminate withdrawal bleeding and aid compliance, the continuous combined regimen was introduced and has gained in popularity. In theory, a small dose of progestin daily counteracts the endometrial proliferation caused by estrogen. Within several months, the endometrium can become atrophic and amenorrhea results. But with this regimen, it is important for women to understand that they may experience some breakthrough bleeding, especially during the first 4 to 6 months. Studies on the use of continuous combined HRT show that the incidence of unscheduled bleeding decreases with the length of treatment (Figure 14).(58) Women who are informed and prepared for this event are more likely to adhere to therapy. In addition, because smaller doses of progestin are used, there may be fewer progestin-related side effects.

Figure 14

When irregular bleeding persists with the continuous combined regimen, an endometrial biopsy may be warranted to rule out endometrial cancer. According to the American College of Physicians (ACP), women on continuous combined HRT should undergo an endometrial biopsy if bleeding is heavy (heavier than normal menstrual period), prolonged (longer than 10 days at a time), or frequent (more often than monthly), or if bleeding persists longer than 10 months after initiating therapy.(59) For women using a cyclic HRT regimen, the ACP guidelines indicate that an endometrial biopsy should be performed only if bleeding occurs at other than the expected time of withdrawal bleeding or if bleeding persists for more than 10 days.

Once a patient has been identified as an appropriate, and interested, candidate for HRT, there are several components of nursing management. Assessment involves gathering the information listed in Figure 15. The nursing checklist on page 27 (Menopausal and Midlife Nursing Assessment) goes beyond a simple history and physical examination to include patient attitudes and concerns. Understanding a patient's expectations of HRT, her lifestyle habits, and any other medications or herbal remedies that she is using will help the nurse tailor patient counseling. This is also an important time to discuss some of the inconveniences that can occur with HRT. Estrogen may initially cause some breast tenderness. It is important for women to know that such discomfort is unrelated to breast cancer and that this tenderness is similar to the premenopausal state. Also, progestin may cause some fluid retention and mood swings, similar to premenstrual tension. Some women tolerate continuous progestin at a low dose better than cyclic dosing.

Figure 15

A checklist of patient concerns might include the following:

• Skin changes/appearance – estrogen can relieve dryness
• Sexuality – difficult or painful sex can be improved
• Breast changes – breast pain is seldom a signal of cancer
• Fertility – the monthly bleeding produced by HRT does not mean the return of fertility
• Cost of medication
• Variation of regimen/dosages – not all estrogens are the same
• Sleep issues – controlling hot flushes will provide better sleep
• Mood alteration – sleep disturbance may be the cause of this
• Weight gain – estrogen is not associated with weight gain

right dosage and regimen for them may take some time, can greatly enhance compliance. In addition, starting with a very low dose of estrogen or gradually increasing doses as tolerated may enhance acceptance. Many women who are given a prescription for HRT never get it filled, and the rate for those who will drop out within the first year of therapy is very high. It is important for women to realize that for the maximum benefits of HRT, therapy may last as long as 20 to 30 years. New single-pill products may aid in compliance by eliminating the need to take 2 pills. In addition, such formulations erase the confusion surrounding which cycle day it is and when to start the progestin.

The final component of nursing management is follow-up. If the patient develops troublesome side effects with HRT, they are likely to occur within the first 3 months of therapy. Thus, a repeat visit at 1 month is critical to assess patient reaction and to reinforce the importance of compliance. Follow-up visits after 2 or 3 months of HRT are needed for women who have difficulty adjusting to their regimen. As always, women should be encouraged to call with questions and problems. Finding the right HRT regimen for each patient takes time and patience. Follow-up, however, should not be limited to the woman who opts for HRT. Rather, this should become a consistent thread in future patient visits. Women who refuse HRT at 50 may change their minds later, and it is never too late to start HRT and gain some of its health benefits. Because there are many facets to HRT, nursing counseling plays a critical part in helping women preserve health beyond menopause.