Menopausal Hormone Therapy

Abstract

Hormone therapy is the most effective treatment for managing menopausal vasomotor symptoms. Hot flashes and night sweats affect approximately 70% of midlife women and may persist for a decade or longer. 1 Bothersome vasomotor symptoms have a significant adverse effect on sleep, daily functioning, and quality of life. Cognitive and mood symptoms often accompany disruptive hot flashes. Although lifestyle changes and nonhormonal options are available, women with frequent, severe vasomotor symptoms may greatly benefit from hormone therapy. 2 Menopausal hormone therapy also has beneficial effects on bone mineral density and the urogenital tract, reducing fracture risk and managing atrophic changes and associated symptoms known as the genitourinary syndrome of menopause. In the absence of vasomotor symptoms, alternatives to systemic hormone therapy are recommended for managing fracture risk and genitourinary symptoms. Very low doses of estrogen placed directly in the vagina effectively manage the sexual and quality of life symptoms associated with the genitourinary syndrome of menopause with minimal systemic absorption and risk. 3 Many options are available for providing systemic menopausal hormone therapy for the management of vasomotor symptoms (Supplement). Women without a uterus should receive estrogen alone. Women with a uterus require progestogen in addition to estrogen to prevent endometrial hyperplasia. Menopausal hormone therapy typically raises the very low estrogen levels of women during menopause to physiologic levels seen during the reproductive years. Menopausal hormone therapy has a high degree of safety compared with contraceptive doses of hormones, which are supraphysiologic to suppress ovulation. A wide range of doses and formulations are available, and the lowest dose that can manage a woman's symptoms should be used. Maximum hot flash reduction is not seen until approximately 3 months of use, so women should be informed not to expect immediate symptom relief.The most commonly used formulations are the oral pill and transdermal patch, but other options (eg, transdermal gels, vaginal ring) also are available (Supplement). For women with a uterus, many formulations of estrogen-progestogen therapy combine both hormones for greater convenience and cost savings. Estrogen is provided daily, while the progestogen is provided daily (continuous combined) or cyclically for 12 to 14 days a month. Continuous combined regimens typically result in amenorrhea and are preferred by most women. "Breakthrough bleeding" may be a disruptive adverse effect of continuous combined regimens, especially for women early in the menopause transition. Cyclic regimens result in regular, predictable withdrawal bleeding.Transdermal estrogen therapy has many advantages compared with oral therapy, especially for women with obesity or cardiovascular disease risk factors. All estrogen patches contain estradiol (the natural hormone made by the ovaries during the reproductive years), are changed only once or twice weekly, and result i...

Breast Cancer Risk in Postmenopausal Women with Medical History of Thyroid Disorder in the Women's Health Initiative

“…The diminished protective effect of hypothyroidism in women who used MHT is consistent with the results from previous WHI trial arm studies that looked at the effects of MHT on the development of invasive breast cancer. In those studies there was a significantly increased risk in the group who received estrogen (conjugated equine estrogens 0.625 mg) plus 2.5 mg medroxyprogesterone acetate (MPA) after adjusting for confounders [HR 1.96, 95% CI 1.17-3.27] (42,43).…”

Women with low quality of life by cervantes-short form scale choose menopausal hormone therapy

“…The decision to initiate or continue MHT involves a careful assessment (11,12) and women´s choice. This decision can be supported by tools that could help identify the appropriate women for MHT or for others therapeutic alternatives (13,14). Several questionnaires have been described to measure the QoL in postmenopausal women (15)(16)(17)(18)(19)(20)(21), but few are easy and fast to handle in a clinical setting.…”

Menopausal osteoporosis: screening, prevention and treatment

“…Since osteoporosis risk increases steeply with oestrogen withdrawal at menopause, it stands to reason that oestrogen replacement should first be considered for management of osteoporosis in midlife women. (39) This was the case prior to the epochal WHI study in 2002, which reported that the health risks of menopausal hormone therapy (MHT) outweigh its benefits. (40) In recent years, there has been a reconsideration of the data, leading to a more nuanced view of the complex pattern of risks and benefits of MHT.…”

“…Observational studies suggest that benefits outweigh risks for effects on bone, heart, cognition, genitourinary symptoms, sexual function, mood and quality of life. (39) Women without a uterus should receive oestrogen alone. Natural oestrogens administered non-orally in the form of transdermal patches or gels offer advantages such as no increased risk of stroke, venous thromboembolism (VTE) and gallstones through bypassing the first-pass hepatic effect.…”

“…Although risk of stroke increased with oral MHT, it is a rare event in this age group, with an absolute attributable risk of less than 0.5 additional cases per 1,000 women per year. (39) Venous thrombotic events also increased with oral MHT use, but large observational studies do not identify increased risk with transdermal estradiol. (45) Selective oestrogen receptor modulators (SERMs) activate distinct tissue receptors for oestrogen.…”