Iron status (including LIC and cardiac T2*) should be assessed before treatment in order to evaluate its clinical relevance, the need for treatment, and the timing and monitoring of chelation therapy (●●●).
Intensive iron chelation therapy is recommended in iron overloaded patients before treatment (●●●).
Doctors should weigh the risks against the benefits when prescribing combination estrogen plus progestin hormone therapy and counsel the patient accordingly (●●●).
Before starting HRT, each patient should be carefully screened by a physician who should identify an increased risk of thrombophilia and tailor the laboratory testing (●●●).
In TM patients with a known thrombophilic defect (such as deficiency of antithrombin, protein C or protein S) that has been identified through screening the pros and cons of HRT treatment should be discussed with a specialist (●●○). In TM patients with a history of VTE, HRT must be avoided (●●○).
Transdermal estradiol and micronized progesterone seem to be the most “physiologic regimen” with the best safety profile, particularly in women with risk factors for VTE (●●○). Natural progesterone may have a more favorable cardiovascular profile and possibly a reduced risk of breast cancer, although the strongest evidence for endometrial protection is for oral cyclical combined treatment (●●○).
Transdermal patches may result in local skin irritation, and some find them difficult to keep in place (●●○). Advice on correct positioning and rotation of application sites may help. However, if compliance is not fit or if contraception is required, the use of the COC is a reasonable choice (●○○).
Splenectomized TM patients with hypogonadism on HRT should receive antiplatelet or anticoagulant therapy with aspirin or low dose warfarin (●●○).
There are no studies on the effect of HRT on lipids, and little information on bone densitometry in hypogonadal TM women on HRT (●○○).
HRT is contraindicated in acute liver disease. However, once the episode of acute illness has entirely passed, HRT may be initiated (●●○).
Treatment of chronic hepatitis C with new antiviral drugs, and intensive chelation in those with severe liver siderosis (LIC > 7 mg/dry weight) prior to HRT is recommended (●●●).
Limited data from studies on chronic hepatitis or its sequelae in non-TM patients suggest that COC use does not influence the progression or severity of liver fibrosis or development of hepatocellular carcinoma (●○○).
If the serum liver enzymes after one month of HRT rise by more than 100 %, or if baseline serum bilirubin is elevated, liver biochemistry should be repeated monthly for at least three months, and treatment needs to be reconsidered (●○○).
Chronic use of third generation contraceptives or HRT could influence the serum lipid profile, and consequently cause an increase in bile lithogenicity (●○○).
In women with insulin-dependent or non insulin-dependent diabetes COCs use has a limited effect on daily insulin requirements and no effect on long-term diabetes control or progression to retinopathy. COCs must be avoided in case of severe microvascular complications such as nephropathy with proteinuria or active proliferative retinopathy (●●○).
Young and adult women with hypogonadism should be counseled as to alcohol and tobacco avoidance, daily exercise for obesity prevention, and an appropriate diet to achieve optimal cardiovascular health (●●○).
