Hormone therapy guidelines updated

Risks and benefits must be assessed before starting hormone therapy.
Risks and benefits must be assessed before starting hormone therapy.

At a glance

  • Decisions regarding hormone therapy (HT) should be based on an individual risk-benefit assessment.
  • HT is the most effective means of ameliorating hot flushes and their impact on sleep, mood, and quality of life.
  • There is growing evidence that fractures increase when HT is discontinued.
  • The authors of the position satement endorse the lowest effective dose of estrogen as a therapeutic goal.

The North American Menopause Society (NAMS) issued its first position statement on menopausal hormone therapy (HT) in 2002 and has added biennial updates ever since. Groups that have endorsed the 2010 update include the American Medical Women's Association, the Endocrine Society, and the National Association of Nurse Practitioners in Women's Health.

"Research on the extensive data base in this field keeps changing the nuances of how people perceive the risks and benefits," says Margery Gass, MD, executive director of NAMS and clinical professor and consultant at the Cleveland Clinic Center for Specialized Women's Health.

Overall, the evidence summarized in the 2010 update "continues to support what we were saying in 2008," Dr. Gass says. "Risks are generally smaller in younger postmenopausal women. Most people are not saying to use HT as a preventive therapy but to consider it for women who are struggling with moderate to severe menopausal symptoms."

Decisions regarding HT should be based on an individualized risk-benefit assessment that begins with a complete history and physical examination. Such contraindications as a history of blood clots in the legs or lungs, a history of breast cancer, or high risk of stroke or heart disease "should make people reconsider," explains Dr. Gass. In counseling patients, "note that pre-existing conditions could increase the risk of a bad outcome, and go from there."

Treatment of symptoms

All systemic estrogen (ET) and estrogen-progestogen (EPT) products are FDA-approved for the treatment of menopause-related vasomotor symptoms. In fact, HT is the most effective means of ameliorating hot flushes and their impact on sleep, mood, and quality of life.

In about 50% of treated women, however, vasomotor symptoms will recur when HT is discontinued. "It is important for women to have that information up front," says Dr. Gass. "Many women share a misconception that hot flushes are age-related and that if they take hormones long enough, the hot flushes will not be there when they discontinue treatment."

There is little evidence as to whether symptoms are milder or shorter-lived when they recur under these circumstances, but it does appear that the risk is no less with tapering than with abrupt discontinuation.

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