HRT Review

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We perform annual reviews for women taking HRT in order to ensure the medicine is still meeting your needs and that it is still safe to prescribe. This form is designed to make it more convenient for women who are happy with their current HRT and not experiencing any issues.

If you are having any problems with your HRT, would like to switch to a different type of HRT or have any questions please do not use this form and contact the surgery to arrange an appointment.

If you would prefer to speak to a doctor, we would be happy to review your HRT over the phone or in person. Please contact the surgery.

In order to provide you with another prescription of your HRT we need to ask you a number of questions.

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Personal Details

Please double check you've entered the correct email address

May be used to identify you

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HRT Review

For example tablets, patch or gel.

Do you have a hormonal coil in place?: *

This is normally the Mirena coil.

Are you happy for us to add a note to your prescription for oestrogen flagging up the date that your coil change is due?: *

Do you have periods or bleeding with your HRT?: *

Is this: *

Has your bleeding changed?: *

Does your HRT help your perimenopausal/menopausal symptoms?: *

Are you interested in gradually reducing or stopping your HRT?: *

Do you ever miss or forget to take your HRT?: *

Do you need contraception?: *

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

Please ensure this is up to date

If you do not supply a recent reading, we will not be able to issue a prescription. We now have a blood pressure monitor in the surgery if you don't have access to a machine at home.

How many units of alcohol do you drink each week?: *

Do you smoke?: *

Do you have any new breast symptoms?: *

For example: a breast lump, skin changes or nipple discharge. Please note breast screening is offered to women every 3 years between the ages of 50-70

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Medical Background History

Have you had surgery to remove your womb (hysterectomy)?: *

Have you ever had breast cancer?: *

Have any of your parents or siblings been diagnosed with breast cancer?: *

Have you ever had any heart problems?: *

Have you ever had a stroke or mini stroke?: *

Have you ever had a blood clot?: *

For example a pulmonary embolism (PE) or a deep vein thrombosis (DVT)

Have any of your parents or siblings been diagnosed with a blood clot?: *

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Risks of HRT

To continue safely prescribing HRT, we need to ensure that you remain aware of the risks that may be present with HRT

If you are unable to access this link or have any questions or concerns about the risks of HRT please contact the surgery to discuss further with a doctor

Do you feel that for you the benefits of taking HRT outweigh the risks?: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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HRT Review

Risks of HRT

Privacy Consent

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