The North American Menopause Society (NAMS) has updated its 2010 recommendations regarding the use of postmenopausal hormone therapy (HT) based on evidence accumulated subsequent to the previous report. In the decade since the first publication of the results from the Women’s Health Initiative, we have accumulated evidence to indicate that multiple factors influence the effects of hormone therapy, including the type of estrogen used, the way the hormones are given, and the age and recency of menopause of the woman taking the medication. These factors also determine the risks associated with hormone therapy.
The NAMS position statement states that short-term hormonal therapy is appropriate for the management of menopausal symptoms in younger perimenopausal and recently postmenopausal women. According to the reviewed research, neither estrogen therapy (ET) nor combined estrogen-progestogen therapy (EPT) increases the risk of cardiovascular disease in healthy women between the ages of 50 and 59 years. Risk for stroke may be increased; however, it is rare in this younger age group. While the overall risk associated with the use of HT in healthy women less than 59 years of age is low, long-term HT or HT initiated in older women carries greater risks.
With regard to the treatment of depressive symptoms, the NAMS statement noted that the findings were mixed. While some studies indicate that ET may treat depressive symptoms, especially in perimenopausal women, other studies show no benefit of ET for treatment of depression. The authors remark, “Although HT might have a positive effect on mood and behavior, HT is not an antidepressant and should not be considered as such. Evidence is insufficient to support HT use in the treatment of depression.”
The position statement highlighted the following findings:
- For relief of hot flashes, combined estrogen-progestogen therapy (EPT) should be used in women with a uterus as progestogen protects the uterine lining from the cancer-promoting effects of estrogen alone.
- The duration of treatment differs for estrogen therapy (ET) and combined estrogen-progestogen therapy (EPT). For EPT, duration is limited by the increased risk of breast cancer and breast cancer mortality associated with 3 to 5 years of use. A more favorable risk-benefit profile was observed for ET used for a mean duration of 7 years of use; thus, estrogen therapy may provide more flexibility in terms of duration of use.
- Women with premature menopause who are otherwise appropriate candidates for HT can use HT at least until the median age of natural menopause (age 51 years). Longer duration of treatment can be considered if needed for symptom management.
- Although ET did not increase breast cancer risk in the Women’s Health Initiative (WHI), there is a lack of safety data supporting the use of ET in breast cancer survivors, and one randomized controlled trial reported an increased likelihood of recurrence of breast cancer among ET users.
- Both transdermal and low-dose oral estrogen have been associated with lower risks of venous thrombosis and stroke than standard doses of oral estrogen, but evidence from randomized controlled trials is not yet available.
- ET is the most effective treatment of vaginal atrophy; low-dose, local vaginal ET is advised when only vaginal symptoms are present.
This statement acknowledges that it is impossible to generate guidelines that can be used for all women. The decision to use hormone therapy must be made on a case-by-case basis, where the clinician takes into consideration the severity of the woman’s symptoms and their effect on her quality of life, as well as her personal risk factors for complications associated with hormone therapy (i.e., venous thrombosis, cardiovascular disease, stroke, and breast cancer). Overall, these findings are reassuring. While some women, specifically older postmenopausal women and those with certain risk factors, may not be good candidates for hormone therapy, estrogen remains a viable treatment option for many women with bothersome menopausal symptoms.
Ruta Nonacs, MD, PhD
Hadine Joffe, MD, MSc
Position Statement: The 2012 Hormone Therapy Position Statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society. 2012;19(3):257-271.