HRT (Hormone replacement therapy) Repeat Review Form

***If you have not already done so, please arrange a blood pressure check at the surgery, or submit a home blood pressure reading.***

Last Updated: 24/10/2024

  • Patient Details

    Date of Birth
    For example, 15 3 1984
    Consent to SMS Text
    Have you had a hysterectomy (operation to remove your womb)
    Do you have a coil that releases hormones fitted (eg mirena) (optional)
    Are you happy with your current HRT prescription
    Have you experienced any new bleeding or change in bleeding pattern since your last HRT review
    Have you experienced any side effects
    Have you ever been diagnosed with a clot in the leg (DVT) or lung (PE)
    Have you ever been diagnosed with breast cancer
    Have you ever been diagnosed with ovarian cancer
    Have you ever been diagnosed with a stroke or mini stroke
    Have you ever been diagnosed with liver disease
    Do you smoke
    Please Confirm You Have Read The Following - HRT is associated with an increased risk of certain conditions including clots, breast cancer and ovarian cancer. It is important you remain aware of these increased risks as well as the benefits of HRT. More information on the risks and alternatives available at - patient.info/womens-health/menopause/hormone-replacement-therapy-hrt ***Please report any irregular vaginal bleeding, calf pain or swelling, sharp chest pain, shortness of breath or coughing up blood.***Please inform a health care professional if you are having an operation scheduled or a period of immobilisation eg leg in plaster.
    Please remember that HRT is not a form of contraception and you will require additional contraception unless you are: - Aged 50 or over and have not had a period in over a year - Aged <50 and have not had a period in 2 years - Aged 55 or over Do you need to discuss additional contraception (optional)
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