The Endocrine Society has recently issued a Clinical Practice Guideline (CPG) on identifying women who are candidates for treatment of menopausal symptoms and selecting the best treatment options for each individual.
Menopause is the life stage that takes place when a woman’s ovaries dramatically decrease production of the hormones estrogen and progesterone, and her menstrual periods stop. The average age of women experiencing menopause is around 51 years old.
A large number of women opt for hormone therapy for menopausal symptoms. A large government study called the Women’s Health Initiative (WHI) reported that hormone therapy – specifically the combination of conjugated equine estrogens and medroxyprogesterone acetate (Prempro) – increases the risk for blood clots, stroke, breast cancer and heart attacks in postmenopausal women aged 50 to 79 years.
In the CPG, the Endocrine Society recommends that women with a uterus who decide to undergo menopausal hormone therapy with estrogen and progestogen should be informed about risks and benefits, including the possible increased risk of breast cancer during and after discontinuing treatment. Health care providers should advise all women, including those taking menopausal hormone therapy, to follow guidelines for breast cancer screening.
Other recommendations from the CPG include:
- Transdermal estrogen therapy by patch, gel or spray is recommended for women who request menopausal hormone therapy and have an increased risk of venous thromboembolism – a disease that includes deep vein thrombosis.
- Progestogen treatment prevents uterine cancer in women taking estrogen for hot flashrelief. For women who have undergone a hysterectomy, it is not necessary.
- If a woman on menopausal hormone therapy experiences persistent unscheduled vaginal bleeding, she should be evaluated to rule out endometrial cancer or hyperplasia.
- Medications called selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin or pregabalin are recommended for women who want medication to manage moderate to severe hot flashes, but either prefer not to take hormone therapy or have significant risk factors that make hormone therapy inadvisable.
- Low-dose vaginal estrogen therapy is recommended to treat women for genitourinary symptoms of menopause, such as burning and irritation of the genitalia, dryness, discomfort or pain with intercourse; and urinary urgency or recurrent infections. This treatment should only be used in women without a history of estrogen-dependent cancers.
Benefits of Hormone Replacement Therapy
For most symptomatic women, use of HRT for five years or less is safe and effective. Benefits of HRT include:
- Reduction in vasomotor symptoms
HRT is the most effective treatment at reducing vasomotor symptoms. Vasomotor symptoms are usually improved within four weeks of starting treatment and maximal benefit gained by three months. There has been shown to be a significant mean reduction in the frequency of hot flushes by around 18 a week and in the severity of hot flushes by 87% compared with placebo Improvement in quality of life
- HRT may also improve sleep, muscle aches and pains and quality of life in symptomatic women.
- Short-term HRT may improve mood and also depressive symptoms.
- Improvement of urogenital symptoms
Various studies have shown that HRT significantly improves vaginal dryness and sexual function. HRT is effective in improving the symptoms related to vaginal atrophy. HRT may also relieve the symptoms of urinary frequency, as it has a proliferative effect on the bladder and urethral epithelium. Topical oestrogen is very effective in improving urinary symptoms in menopausal women. Vaginal symptoms are improved, vaginal atrophy and pH decrease and there is improved epithelial maturation with topical oestrogen preparations compared to placebo or non-hormonal gels.
- Reduction in osteoporosis risk
HRT is effective in preserving bone mineral density. Taking HRT leads to a reduction in osteoporosis in the spine and hip. Women taking HRT have a significantly decreased incidence of fractures with long-term use. HRT is the first-line treatment for the prevention and management of osteoporosis in women with menopausal symptoms who are under the age of 50 years. HRT should be considered in those women at high risk of fracture if there are no contra-indications to HRT. The bone protection qualities of HRT are dose-related. Although bone density declines after discontinuation of HRT, some studies have demonstrated that women who take HRT for a few years around the time of the menopause may have a long-term protective effect for many years after stopping HRT.
- Reduction in cardiovascular disease
The relation between HRT and cardiovascular disease is controversial, but the timing and duration of HRT, as well as pre-existing cardiovascular disease, are likely to affect outcomes. The Women’s Health Initiative (WHI) trial demonstrated that there was a small increase in the incidence of coronary heart disease in the first year after starting HRT (women in this trial were taking conjugated equine oestrogens with or without medroxyprogesterone acetate). Women who start HRT when they are aged over 60 years have an increased risk of coronary heart disease. A recent study has shown that HRT reduces the incidence of coronary heart disease by around 50% if it is started within ten years of the menopause. This study also demonstrated that women receiving HRT early after menopause had a significantly reduced risk of mortality without any apparent increase in risk of cancer, venous thromboembolism (VTE) or stroke.A nother RCT showed that there is a neutral impact on cardiovascular disease risk markers (eg, coronary calcium scores and intima thickness) in women who were given low-dose HRT within three years of their last period.
- HRT has a protective effect against connective tissue loss and may even reverse this process. Some studies have shown an improvement in cognition in women who started HRT in early menopause; others have not shown this benefit.
- There is a possible reduction in the long-term risk of Alzheimer’s disease and all-cause dementia in those women who take HRT. However, further studies are needed to be undertaken in this area.
Note: The CPG, entitled “Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline,” was published online and will appear in the November 2015 print issue of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society.