Short-term hormone replacement therapy (HRT) is acceptable and relatively safe for healthy, symptomatic, recently postmenopausal women, according to a new consensus statement endorsed by 15 leading medical organizations involved in women's health.
The new guidelines and rationale were issued jointly by the North American Menopause Society (NAMS), the American Society for Reproductive Medicine, and the Endocrine Society.
More than a decade ago, on July 9, 2002, findings from the Women's Health Initiative (WHI) stirred up controversy by showing that for the prevention of chronic disease, risks for HRT outweighed the benefits.
"The results of the WHI and the conflicting reports that followed led many women to believe hormone therapy may not be a safe treatment for menopausal symptoms," Janet E. Hall, MD, immediate past president of the Endocrine Society, said in a news release. "We want women to know that there are options out there for relief of their menopausal symptoms. The level of risk depends on the individual, her health history, age, and the number of years since her menopause began."
In the aftermath of the WHI report, some clinicians may have erred on the side of caution, hesitating to provide even short-term HRT to appropriately selected patients for relief of perimenopausal symptoms. Although HRT is widely thought to be effective in this setting, the reluctance of physicians to prescribe it may have led symptomatic women to seek unproven alternative treatments.
"Many women can safely take hormone therapy for relief of menopausal symptoms when they work closely with their provider to assess their personal risks and benefits," NAMS Executive Director Margery Gass, MD, said in a news release. "Women and clinicians have been frustrated by the many conflicting recommendations during the last 10 years. This statement should be reassuring to all."
The joint statement aimed to present evidence-based key concepts about appropriate use of HRT to facilitate informed decision-making by women and their physicians.
"Physicians can help patients determine, based on their own particular characteristics and history, whether or not they are good candidates for hormone therapy and what type of [therapy] will provide them the greatest relief at the lowest risk," said Roger Lobo, MD, past president of the American Society for Reproductive Medicine. "A decade of research and analysis has shown us that the generalized conclusions of the WHI do not apply to younger women at the beginning of the menopausal transition."
Specific recommendations in the consensus statement include the following;
In addition to the North American Menopause Society, the American Society for Reproductive Medicine, and the Endocrine Society, which collaborated on the joint statement and published it in their journals, 12 other medical organizations endorsed the consensus guidelines. All conclude that hormone therapy has an important role in managing symptoms for women during the menopausal transition and in early menopause.
- The decision to use HRT must be individualized based on specific patient factors and anticipated risks and benefits. These include quality-of-life priorities, age, time since menopause, and risk for blood clots, heart disease, stroke, and breast cancer.
- For healthy, relatively young women (younger than 59 years or within 10 years of menopause) with moderate to severe menopausal symptoms, systemic HRT is an acceptable option and is the most effective treatment.
- Low-dose vaginal estrogen is the preferred treatment for women who have only vaginal dryness or discomfort with intercourse.
- To prevent uterine cancer in women who still have a uterus, HRT should include progesterone or a similar progestogen, as well as estrogen. Women who have undergone hysterectomy can be given only estrogen.
- Estrogen-only and estrogen-progestogen HRT are associated with increased risk for stroke and of venous thromboembolism (deep venous thrombosis and pulmonary embolus), as are hormone-based contraceptives. However, the risk is rare in women aged 50 to 59 years.
- Use of continuous estrogen with progestogen therapy for at least 5 years, and possibly even for shorter duration, is associated with an increased risk for breast cancer. The risk is real, but not great and when HRT is discontinued, this risk decreases. Use of estrogen alone for 7 years in the WHI trial did not increase the risk of breast cancer.
- The lowest effective dose of hormone therapy should be used for the shortest time to manage menopausal symptoms. Continued use should be reevaluated periodically, but duration should be individualized and some women may require extended therapy because of persistent symptoms.