22. Menopausal HRT: the endometrial‑protection rule

First principle: replace estrogen — but oppose it if there's a uterus

This is Concept 7's predictive rule applied therapeutically.

Individualising the decision

HRT is offered for vasomotor symptoms/GSM and quality of life, weighing symptoms, age/time since menopause, and personal risk (VTE, breast cancer, cardiovascular). It is not a blanket prescription for every menopausal woman; the regimen (cyclical vs continuous‑combined, oral vs transdermal) is tailored.

Adjacent priorities

• Bone: calcium/vitamin D, weight‑bearing exercise, DXA for risk, and specific agents (bisphosphonates, etc.) when indicated.
• GSM: local vaginal estrogen is effective and has minimal systemic absorption (usable even when systemic HRT is unsuitable).

Pitfalls

• Unopposed estrogen with an intact uterus — a predictable oncogenic error. 🚩
• Withholding local vaginal estrogen out of unwarranted fear of systemic risks.

Pearls

• 🎯 Intact uterus → add a progestogen. The single most testable — and protective — HRT rule.
• 🩺 Transdermal estrogen carries lower VTE risk than oral — useful in higher‑risk women.

Next → We now leave endocrinology for structure — anatomy through a surgeon's eyes (Concept 23).