HRT Annual Review

DD slash MM slash YYYY

What is your most recent Blood Pressure reading? (This can be checked at reception, home or work).

I confirm I am currently taking my HRT
If you have a uterus please confirm this includes the progesterone component eg Mirena in date (5 years since insertion), utogeston or combined HRT as advised
Have you had a hysterectomy?
Do you have a mirena coil in place, that was inserted in the last 5 years?
What is the reason for you taking HRT?

Do you have a history of Endometriosis?
What is your smoking status?
Do you have parents, brothers, sisters or children who have had heart disease or stroke under the age of 45 years?
Do you have parents, brothers, sisters or children who have had a blood clot (sometimes called a deep vein thrombosis or pulmonary embolus)?
Do you have, or have you had a blood clot?
Do you have any blood clotting abnormalities?
Do you have any family history of breast cancer under the age of 50?
Have you had breast cancer?
Do you have migraines?
Do you have periods or bleeding with your HRT?
Have you had any unexpected bleeding since starting HRT including after sex?
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?

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

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)
You understand that you should tell a healthcare professional; that you are on HRT (if you taek oral oestrogen) if you need to have an operation or have a period of prolonged immobilisation e.g. leg in plaster:
You understand that irregular vaginal bleeding on HRT should be reported to a clinician:

Smear Tests

For information on smear tests, please visit

Please note if you find smears uncomfortable you may benefit from some additional vaginal oestrogen pessaries/cream and we would be happy to prescribe these to support you if appropriate.

Are you up to date with your smears (5 yrly age 50-64yrs)?

Breast Screening

For information on breast screening, please visit

If you are over 50, are you up to date with your breast screening? Breast screening is normally every 3yrs for ages 50-70 yrs
Do you have any breast symptoms that weren’t here before eg lump, nipple discharge

HRT Information and Leaflet

There is little or no increase in breast cancer risk if you take oestrogen only HRT or transdermal oestrogen with utrogestel. Combined HRT can be associated with a small increased risk. Using vaginal oestrogen for vaginal symptoms is very safe.

Please read the following NHS information:

HRT is not a contraceptive. The Mirena is also a contraceptive method. In general all women can stop contraception at the age of 55 yrs.

Do you need contraception?
This field is for validation purposes and should be left unchanged.