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Clinical Audit: Reviewing the use of menopausal hormone therapy

This audit helps health professionals in primary care identify women who are taking menopausal hormone therapy (MHT) to assess whether they have had a review of the benefits and risks of treatment in the past 12 months.

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Published: 13 December 2019

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MHT is the most effective treatment for the vasomotor symptoms and urogenital atrophy associated with menopause, however, it is associated with an increased risk of adverse outcomes such as breast cancer, stroke and venous thromboembolism (VTE). The extent of risk depends on on the timing or age at initiation, MHT type, dose, duration of use,* route of administration, and whether a progestogen is used.

* Stroke and VTE risk are do not appear to be influenced by the duration of treatment, but are influenced by the woman’s age.

The benefit-risk ratio of MHT is most favourable for women aged < 60 years or who are within ten years of menopause. The absolute risk of adverse events such as VTE or stroke is low in this group and are likely outweighed by the benefits of treatment for women who have menopause symptoms affecting their quality of life. Non-hormonal treatments, e.g. SSRIs or SNRIs, may be suitable for women with vasomotor symptoms who have contraindications to using MHT or do not wish to use it. Topical vaginal products are recommended instead of MHT for women who primarily have urogenital symptoms, e.g. moisturisers, lubricants or a vaginal oestrogen cream or pessary.

All women taking MHT should have an annual review to determine whether ongoing treatment is appropriate, which takes into consideration any change in risk factors, e.g. for cardiovascular disease or breast cancer, and the extent of benefit. Guidelines do not recommend an upper limit on the duration of MHT; women who initiated MHT at a younger age can continue treatment beyond age 60 years if they feel it is beneficial and there are no new contraindications, e.g. an oestrogen-dependent cancer or cardiovascular event.

For further information on prescribing MHT and the risks and benefits associated with treatment, see: Menopausal hormone therapy: where are we now?


This audit identifies women who are taking MHT to assess whether they have had a review of the benefits and risks of continuing treatment in the past 12 months.

Recommended audit standards

Ideally, all women who are prescribed MHT should have a documented review of the benefits and risks of treatment in their clinical notes in the past 12 months. If there is no evidence of this, the patient should be flagged for review.

Identifying eligible women

You will need to have a system in place that allows you to identify women who are taking MHT. Many practices will be able to do this by running a “query” through their PMS.

Sample size

The number of eligible women will vary according to your practice demographic. It is unlikely that a large number of results will be returned, but if so, take a random sample of 20–30 women.

Criteria for a positive outcome

For a positive result for the audit, the woman’s clinical notes should contain a record of a review of the benefits and risks of MHT in the past 12 months.

The benefits of MHT will most likely be based on the subjective assessment by the woman. Most women who have been using MHT for a number of years will not know if they are still having symptoms that affect their quality of life, unless MHT has been stopped recently and their symptoms recurred.

The risk assessment should include:

  • The woman’s age
  • An update of cardiovascular disease history and risk, e.g. BMI, smoking, blood pressure, diabetes, any cardiovascular events
  • An update of breast cancer history and risk, including whether there is a record of regular mammograms
  • Whether the woman has any unexplained vaginal bleeding

* Breast cancer screening with mammography is recommended every two years for women aged 45–69 years

Data analysis

Use the sheet provided to record your data. A positive result is any woman taking MHT who has evidence in her notes of a review of the benefits and risks of treatment. The percentage achievement can be calculated by dividing the number of women with a positive result by the total number of women audited.

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • Identifying barriers can provide a basis for change
  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that the doctor completes the first part of the Audit of Medical Practice summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices complete the remainder of the Audit of Medical Practice summary sheet.

Claiming credits for Te Whanake CPD programme requirements

Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).

Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.

To claim points go to the RNZCGP website:

If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the RNZCGP website).

N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.

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