Hormone therapy focus of new joint statement

The North American Menopause Society, the American Society for Reproductive Medicine, and The Endocrine Society have issued a joint statement concluding that hormone therapy (HT) is still an acceptable treatment for menopausal symptoms.1 The statement has been endorsed by 12 other medical societies. (Access a copy of the statement at http://bit.ly/MVMfha. See list of endorsing societies, below.)

Groups That Endorse Joint Statement on Hormone Therapy

Academy of Women's Health
American Academy of Family Physicians
American Academy of Physician Assistants
American Association of Clinical Endocrinologists
American Medical Women's Association
Asociación Mexicana para el Estudio del Climaterio
Association of Reproductive Health Professionals
National Association of Nurse Practitioners in Women's Health
National Osteoporosis Foundation
SIGMA Canadian Menopause Society
Society for the Study of Reproduction
Society of Obstetricians & Gynaecologists of Canada


Hormone therapy is considered an acceptable option for the "relatively young" (defined as up to age 59 or within 10 years of menopause) and healthy women who are bothered by moderate to severe menopausal symptoms, according to the joint statement.1

"Individualization is key in the decision to use hormone therapy," the statement reads. "Consideration should be given to the woman's quality-of-life priorities, as well as her personal risk factors such as age, time since menopause, and her risk of blood clots, heart disease, stroke, and breast cancer."

The statement makes it clear that a large number of clinicians are in agreement that hormone therapy is an acceptable option for the management of menopausal symptoms for most women, says Margery Gass, MD, executive director of the North American Menopause Society. When the risks of hormone therapy were published in 2002, many clinicians and women themselves turned away from using hormone therapy, not only for long-term use, which was appropriate, but they also rejected any use at all, she notes.

"This statement is intended to reassure women and their providers that short-term use of hormone therapy is still an acceptable option for most women who are experiencing moderate to severe menopausal symptoms," states Gass.

According to the joint statement, hormone therapy is the most effective treatment for menopausal symptoms such as hot flashes and vaginal dryness. For women with vaginal dryness or discomfort with intercourse, the preferred treatments are low doses of vaginal estrogen. Hot flashes generally require a higher dose of hormone therapy that will have an effect on the entire body, the statement advises.

Women with an intact uterus should take a progestogen — progesterone or a similar product — along with the estrogen to prevent cancer of the uterus, the statement reads. While five years or less is usually the recommended duration of use for the combined treatment, length of time can be individualized for each woman, the statement reads. Women who have had their uterus removed can take estrogen alone; more flexibility can be used in prescribing estrogen therapy due to apparent safety of estrogen-along treatment, the statement advises.

Discuss the risks

A discussion of hormone therapy must include the potential risks of the method. Both estrogen therapy and estrogen with progestogen therapy increase the risk of blood clots in the legs and lungs, similar to birth control pills, patches, and rings, the joint statement notes. Although the risks of blood clots and strokes increase with either type of hormone therapy, the risk is rare in the 50-59 year old age group, the statement reads.

How about breast cancer? The statement notes that an increased risk in breast cancer is seen with five or more years of continuous estrogen/progestogen therapy, and it may be documented earlier. However, the risk decreases after hormone therapy is stopped, the statement reads. Use of estrogen alone for an average of seven years in the Women's Health Initiative trial did not increase the risk of breast cancer, the statement notes.

Available evidence suggests that estrogen therapy applied to the skin through patches, gels, and sprays and low-dose estrogen pills have been associated with lower risks of blood clots and strokes than standard doses of estrogen pills, but studies directly comparing oral and transdermal hormone therapy have not been done, the statement notes.

There are many forms of hormone therapy that have received clearance through the Food and Drug Administration (FDA), the statement reads. Scientific data is not available to determine whether custom compounded bioidentical hormone therapy is any safer or more effective than FDA-approved hormone therapies, the statement says.

Until research identifies the harms and benefits of the variety of available hormone regimens, women should be cautious about unproved claims, advises the 2011 edition of "Our Bodies, Ourselves."2 Data suggests that estrogen given through the skin (transdermal estradiol) bypasses the liver and is less likely to cause blood clots and possible strokes than pills, the book states.3 However, transdermal estrogen appears to carry the same breast cancer risk as oral estrogen, the book notes.4

Use "Menopause Map"

How can you and your patient enter into a productive dialogue about treatment of menopausal symptoms? Look to the "Menopause Map," an online interactive tool that guides a woman through available options. (Access the tool at http://bit.ly/Nrg6h7.)

Developed by The Endocrine Society and the Hormone Health Network, the map uses a series of prompting questions about symptoms and a patient's personal health history. It also has links to questionnaires that help assess current risk for breast cancer, heart disease, and stroke. The tool weighs hormonal and non-hormonal therapies against the risks based on individual symptoms and medical history.

The map is quick and easy to navigate, says Cynthia Stuenkel, MD, a developer of the Menopause Map. Most women run through the questions several times, offering different responses to check out their various options. This online encounter provides the woman with a dry-run before her official conversation with her provider, says Stuenkel, an endocrinologist specializing in menopause at the University of California, San Diego. The map allows the woman to print out her responses to take with her to the appointment.

"For some women, having their answers in hand in a printed form might help initiate the conversation about menopausal symptoms and options for relief, while she can focus her questions on the issues and options that most resonate with her," she notes.

The goal of the Menopause Map is to have each woman as informed as possible about her options to relieve specific symptoms and address other health concerns, such as risk of heart disease, osteoporosis, and breast cancer, says Stuenkel.

"We are each individuals with our own specific health profile and life story," she says. "Relief of menopausal symptoms should accordingly also be individualized."

References

  1. Stuenkel CA, Gass ML, Manson, JE, et al. A decade after the Women's Health Initiative -- the experts do agree. J Clin Endocrinol Metab 2012; 97(8):2,617-2,618.
  2. Boston Women's Health Book Collective. Our Bodies, Ourselves. New York: Simon & Schuster; 2011.
  3. Speroff L. Transdermal hormone therapy and the risk of stroke and venous thrombosis. Climacteric 2010; 13(5):429-432.
  4. Fournier A. Should transdermal rather than oral estrogens be used in menopausal hormone therapy? A review. Menopause Int 2010; 16(1):23-32.