HRT HRT Contraindications & Risk Factors 2 — Questions and Answers
Question 1: Which personal medical history item should be elicited FIRST when screening a new patient for HRT candidacy?
- Personal or family history of hormone-sensitive cancers and blood clots (Correct answer)
- Current shoe size
- Dietary preferences
- Exercise frequency
Correct answer: Personal or family history of hormone-sensitive cancers and blood clots
Hormone-sensitive cancers (breast, endometrial) and prior VTE are the most critical red flags that may contraindicate HRT and must be identified at initial screening.
Question 2: A patient with a BRCA1 mutation who has undergone risk-reducing bilateral mastectomy and oophorectomy — is HRT contraindicated?
- No — breast tissue is removed, so estrogen-driven breast cancer risk is dramatically reduced (Correct answer)
- Yes — BRCA1 absolutely prohibits HRT in all circumstances
- Only estrogen is safe; progesterone is still contraindicated
- She can only use vaginal estrogen
Correct answer: No — breast tissue is removed, so estrogen-driven breast cancer risk is dramatically reduced
After risk-reducing bilateral mastectomy and oophorectomy, HRT is generally considered acceptable because the primary target organ for BRCA1-linked breast cancer has been removed.
Question 3: In a patient with controlled hypertension, which HRT route is generally preferred to avoid further BP elevation?
- Transdermal estrogen (Correct answer)
- Oral conjugated estrogen
- Oral synthetic progestin only
- IV progesterone
Correct answer: Transdermal estrogen
Oral estrogen increases hepatic synthesis of angiotensinogen, which can raise blood pressure, whereas transdermal estrogen has a neutral effect on the renin-angiotensin system.
Question 4: Gallbladder disease risk is specifically associated with which route of estrogen administration?
- Oral estrogen (Correct answer)
- Transdermal estrogen
- Vaginal estrogen
- Subcutaneous pellet estrogen
Correct answer: Oral estrogen
Oral estrogen increases biliary cholesterol saturation through hepatic first-pass processing, raising the risk of gallstone formation and gallbladder disease.
Question 5: For a patient with a history of hormone receptor-negative breast cancer in complete remission, how should HRT candidacy be approached?
- Individualized shared decision-making with oncology input, as absolute contraindication is less clear than for ER+ cancer (Correct answer)
- HRT is absolutely contraindicated regardless of receptor status
- HRT is fully unrestricted after 1 year of remission
- Only progestogen is permitted
Correct answer: Individualized shared decision-making with oncology input, as absolute contraindication is less clear than for ER+ cancer
Hormone receptor-negative breast cancers are not stimulated by estrogen, making the contraindication less absolute, but oncology consultation and individualized risk discussion remain essential.
Question 6: Which cardiovascular risk factor, if present in a woman under 60, does NOT necessarily preclude low-dose transdermal HRT for menopausal symptoms?
- Well-controlled hypertension without end-organ damage (Correct answer)
- Recent MI within 6 months
- Active STEMI
- Unstable angina
Correct answer: Well-controlled hypertension without end-organ damage
Well-controlled hypertension without end-organ damage in a woman under 60 is generally considered a relative, not absolute, contraindication when using transdermal HRT.
HRT HRT Contraindications & Risk Factors 2
Which personal medical history item should be elicited FIRST when screening a new patient for HRT candidacy?