Medication & HRT review

We review any medication on a repeat prescription annually and wherever possible the doctor will do this without you having to attend the surgery. Certain medications need regular monitoring, which may include blood tests and/or blood pressure checks. You will be contacted by our team if this is required.

If you have been advised by the surgery that your medication review is due please use this form.

Please ensure that you complete any outstanding blood test requests prior to filling out this form. You will know if you need to have a blood test by reading the prescription note or text message you were sent by us.

Hormone replacement therapy (HRT) is a treatment to relieve symptoms of the menopause. It replaces hormones that are at a lower level as you approach the menopause. The main benefit of HRT is that it can help relieve most of the menopausal symptoms, including: hot flushes, night sweats, mood swings, vaginal dryness and reduced sex drive. Many of these symptoms pass after a few years, but they can be unpleasant and taking HRT can offer relief for many women.

Whilst the benefits of HRT often outweigh the risks, some types of HRT can increase your risk of breast cancer and blood clots. It is important to remain vigilant for signs of breast cancer and we encourage you to attend breast screening when invited.

Please review the information pages below before completing this form:

Information page on HRT
HRT & Risk of Breast Cancer
Infographic on the risks of HRT (EXTERNAL PDF LINK)
Antidepressant review mood questionnaire calculator

To ensure your medication is prescribed safely and you are aware of all this information we review your prescription every 12 months. If your review is now due please complete the following form and fill in as much information as possible. Some of this information will already be included in your medical records but this is a good opportunity to update any changes.

Medication & HRT review

Step 1 of 3

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Full Name Required

Date of Birth Required

Day

Month

Year

Contact Number (preferably mobile) Required

Do you have any concerns or side effects from your medication? Required

Yes: but I want to continue taking it

Yes: I would like to stop the medication

Please explain what side effects or issues you have experienced Required

Do you know when and how to take your medication? Required

Yes

Please record your most recent home/hospital/pharmacy blood pressure RequiredIt is really important to try and get a home reading as this will help speed up the process. If no reading is given you will need to attend the practice to have your blood pressure taken.

Are you on antidepressant medication? Required

Yes

Please state what score you calculated on the mood questionnaire PHQ-9 (LINK ABOVE). OptionalPlease note that if your mental health is currently significantly impact and you are concerned for your well-being you must contact the crisis team on 0300 200 0011 and select option 1 or 999.

Please enter a number from 0 to 29.

If you are on antidepressants, can you please select the option which best applies to you? OptionalIf you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.

I would like to continue on the current dose

I would like to reduce my dose

I would like to increase my dose

I would like to try an alternative

I would like to stop them

Do you take an over the counter, herbal remedies or specialist medication? RequiredIf no write: NO. If yes, please state the name and dose of these medications.

HRT Review

Please give details about your current HRT regime. Whilst this will be on your medical records it can be important to clarify exactly what type of HRT you are using Required

Are you happy with your current HRT? Required

Yes - I would like to continue

Yes - But I would like to change the dose

Yes - But I would like to change the form

No - I would like to change

No - I would like to stop any form of HRT

If you would like to change to a different HRT regime (or are having problems finding it in stock) do you know what type you would like to change to? Optional

Have you had any problems finding it in stock? Required

Yes: All the time

Yes: Some of the time

Yes: Rarely

No issues

Have you had a total hysterectomy? RequiredA total hysterectomy is where your uterus and cervix have been removed

Yes

Not sure

Do you have a Mirena coil? Required

Yes, it was inserted less than 5 years ago

Yes, but inserted more than 5 years ago

Yes, but I am not sure when it was inserted

If you have a Mirena coil and know its insertion date please enter this here Optional

Do you know when your last period was? Please select the closest date possible Optional

What is your current bleeding pattern? If you are having periods are they still fairly regular? If not, please describe what your bleeding pattern is like RequiredIf you are no longer having periods please indicate this here. You may notice some vaginal bleeding in the first 3 months of starting or changing HRT, but if you experience any bleeding after 3 months then you should see your healthcare professional straight away.

Have you noticed any unusual or unexpected bleeding? If yes, please give details. If no state 'no'. RequiredYou may notice some vaginal bleeding in the first 3 months of starting or changing HRT, but if you experience any bleeding after 3 months, or heavy/unusual bleeding then you should see your healthcare professional straight away.

Is your smear test up to date? RequiredPlease note those aged 25 to 49 should have a smear test every 3 years. For those aged 50 to 64 it is every 5 years. While those over 65 will only need one if 1 of your last 3 tests was abnormal.

Yes

Not sure

Not required due to surgical removal

Do you have a history of breast cancer or does it run in your family? RequiredOut of 1,000 women taking HRT between the ages of 50-59, there will be an extra 4 cases of breast cancer diagnosed every 5 years. If you use oestrogen only HRT there are 4 fewer cases diagnosed.

Yes

Do you have a personal or family history of ovarian cancer? RequiredA recent study found that for every 1,000 women taking HRT for 5 years, there will be 1 extra case of ovarian cancer

Yes

Is there any personal or family history of blood clots? RequiredIt is thought that the risk of developing a blood clot is 2 to 4 times higher than normal for women taking HRT tablets. But as the risk of menopausal women developing blood clots is usually very low, the overall risk from taking HRT tablets is still small. It is estimated that for every 1,000 women taking HRT tablets for 7.5 years, fewer than 2 will develop a blood clot. Please note that there is no increased risk of blood clots when using HRT patches or gels

Yes

Have you had a heart attack or stroke or do you have a first degree relative (parents, siblings or children) who has had a heart attack or stroke? RequiredThe evidence shows that HRT does not significantly increase the risk of cardiovascular disease (including heart disease and strokes) when started before 60 years of age. Oestrogen-only HRT is associated with no, or reduced, risk of heart disease. Combined HRT is associated with little or no increase in the risk of heart disease. Taking oestrogen tablets is associated with a small increase in the risk of stroke, but the risk of stroke for women under age 60 is generally very low, so the overall risk is still small

Yes

If you have a personal or family history of any of the above conditions please give more details here Optional

What is your blood pressure? RequiredYour blood pressure should be checked every 12 months whilst you are taking HRT. Please record it here. Blood pressure machines can be bought from pharmacies, online retailers and most supermarkets. If you are not able to check it yourself please arrange an appointment with one of our health care assistants.

Do you drink alcohol - if yes, how many units do you drink each week? RequiredIf you drink more than 2 units of alcohol each day, out of 1,000 women aged 50-59 there will be an additional 5 cases of breast cancer diagnosed every 5 years.

0 (I do not drink)

1 - 5 units/week

6 - 10 units/week

11 - 15 units/week

16 - 20 units/week

20 - 30 units/week

30 - 45 units/week

>45 units/week

Do you smoke? RequiredIf you are a current smoker, out of 1,000 women aged 50-59 there will be an additional 3 cases of breast cancer diagnosed every 5 years.

Never smoked

Smoker (1-9/day)

Smoker (10-19/day)

Smoker (20-39/day)

Smoker (>40/day)

Ex-smoker

Do you know your height and weight? Please record them here in either metric or imperial units RequiredIf you are overweight or obese (your BMI is equal or greater than 30) out of 1,000 women aged 50-59 there will be an additional 24 cases of breast cancer diagnosed every 5 years.

Do you exercise regularly? RequiredIf you do at least 2.5 hours of moderate exercise each week, out of 1,000 women aged 50-59 there will be 7 FEWER cases of breast cancer diagnosed every 5 years.

0 minutes

1 - 60 minutes

Would you like to discuss contraception? RequiredWhilst a Mirena coil offers contraception other methods of HRT do not.

Yes

Would you like to continue your current HRT regime? RequiredIf you would like to change to a different regime we will call you to discuss this further

Yes, send my prescription to the chemist

Yes, but I would like a call to discuss further

No, I would like to change

If we are able to directly issue your prescription which chemist would you like to collect it from (name & postcode)? Required

I confirm that: Required

The information provided is accurate to the best of my knowledge

I understand the risks associated with HRT

I understand HRT is not a form of contraception (with the exception of the Mirena coil as long as it is within date)

Have you ever had a mammogram? OptionalIf so please let us know the date and the outcome

Consent Required

To view the risks associated with HRT please use the links at the top of this form.

I confirm I am happy to accept the risks associated with using HRT.