Dosage, duration, and route of administration

The authors advocate the lowest effective dose of estrogen and progestogen. Low-dosage formulations are better tolerated and, it is likely but not proven, carry lower risks.

There are no long-term data that show one route of administration clearly superior to another, but observational data suggest that nonoral (e.g., transdermal) administration is preferable for women at increased risk of VTE and those with diabetes. Local estrogen is preferred for vaginal symptoms in the absence of other HT indications.

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According to the authors, using HT long beyond menopause carries increased risks, which, for some women, may be outweighed by the benefits. In contrast to earlier position statements, the 2008 revision terms extended use “acceptable” for women who make this informed choice and for prevention of osteoporotic fracture in women with established bone mass reduction who are not candidates for alternative treatment.

“Bioidentical” hormones

In recent years, the use of custom-compounded HT formulations has increased. These are often based on salivary hormone testing and involve dosages, ingredients, and routes not otherwise available. The authors note that there is no scientific basis for salivary testing and that custom-compounded hormone preparations are untested for safety or efficacy.

While “the positives [may] outweigh the negatives” for a few individuals, “for the vast majority…regulatory agency-approved HT will provide appropriate therapy without assuming the risks and cost of custom preparations,” they say.

Explaining HT risk

The confusion and fear surrounding HT make “ongoing communication of accurate information…essential,” the authors say. The 2008 revision includes an addendum on calculating and explaining risk.

Among the recommendations:

  • Use numbers rather than percentages (“Two out of every 10” women experience a side effect, instead of “there is a 20% risk”).
  • When possible, speak in terms of absolute rather than relative risk (Instead of “the drug doubles heart attack risk,” one might say “Four out of every 1,000 users per year have a heart attack, compared with two out of every 1,000 nonusers”).
  • Keep in mind that fear surrounding health outcomes may be uncoupled from actual risk. Combined estrogen and progestogen is associated with similar risks of stroke and breast cancer, but many women will fear the latter far more than the former. 
  • Communicate information with sensitivity to the individual’s needs: Does she seek actuarial data, the clinician’s informed opinion, or both?

Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society was published in Menopause: The Journal of the North American Menopause Society (2008;15:584-603). The document is available online.

Mr. Sherman is a medical writer in New York City.