Title : Optimising endometrial protection in patients using high-dose transdermal oestrogen: A primary care quality improvement project
Abstract:
Background: Women and people with an intact uterus receiving systemic oestrogen require adequate progesterone to reduce the risk of endometrial hyperplasia and carcinoma. Updated British Menopause Society guidance recommends increased progesterone doses for women using higher-dose transdermal oestrogen. However, patients may alter their oestrogen dose over time without corresponding updates to prescribing records, potentially leading to inadequate endometrial protection.
Aim: To identify patients using high-dose transdermal oestrogen who required optimisation of progesterone therapy in accordance with current guidance and to evaluate whether electronic prescribing records accurately reflected current HRT use.
Methods: A quality improvement project was undertaken within a UK general practice. An electronic search was used to identif patients prescribed transdermal oestrogen. Patients were contacted via text message to confirm their current HRT regimen. Electronic medical records were reviewed to determine prescribed oestrogen dose, actual oestrogen use, progesterone regimen, and the presence of a 52 mg levonorgestrel-releasing intrauterine system or previous hysterectomy. Patients using four or more pumps of transdermal oestrogen were assessed against current guidance regarding endometrial protection and their prescription updated.
Results: 149 patients were identified and contacted via SMS, with 110 women participating in the study. 44 (40%) were using the same oestrogen dose as documented on their prescription, while 66 (60%) were using a different regimen. 20 patients were using four or more pumps daily (including one using 6 pumps). Only 2 out of 20 (10%) patients had an electronic prescription accurately reflecting their current oestrogen dose. Among the remaining 18 patients with inaccurate prescribing records, 7 (39%) required optimisation of progesterone therapy based on their actual oestrogen use.
Conclusions: There was substantial discordance between prescribed and actual transdermal oestrogen use in primary care. Inaccurate prescribing records may contribute to inadequate endometrial protection in women receiving higher-dose HRT. Routine medication reviews should confirm the oestrogen dose patients are actually using and ensure progesterone prescribing remains appropriate. This project prompted prescription updates, targeted clinical review, and the introduction of ongoing quality improvement measures.
