(First of two parts)
It’s time to be clear about the benefits of hormone therapy for many women in midlife.
I want to take fear out of the conversation. Hormone therapy remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture.
Hormone therapy is currently approved by the Food and Drug Administration as first-line therapy to relieve vasomotor symptoms (VMS). Low-dose vaginal estrogen therapy is also a first-line treatment for the genitourinary syndrome of menopause, because it can directly address vulvo-vaginal atrophy.
An additional approved indication for systemic hormone therapy (HT) is the prevention of bone loss and fracture reduction in postmenopausal women who have increased risk of osteoporosis or fracture. It’s also FDA approved for women who had hypogonadism, primary ovarian insufficiency, or premature surgical menopause, who may use HT until the average age of menopause about 52 years.
Unopposed systemic estrogen should not be used as HT in women with an intact uterus because of the elevated risk of endometrial cancer, and all indications assume there are no contradictions to HT use.
The position statement was developed by an expert panel, and has been endorsed by a number of international menopause societies.
Early analysis of cardiovascular health data from the large, prospective Women’s Health Initiative, as well as meta-analyses of randomized controlled trials, have yielded a more nuanced view of the relationship between HT and cardiovascular disease.
Age matters. Data show that there is reduced heart disease in women who start (hormone replacement) early. There is increasing data, to support the “timing” hypothesis.
“Women who start HT before the age of 60 years, or within 10 years of menopause, may have a reduced risk of coronary heart disease. “There is concern of increased risk of (coronary heart disease) in women who initiate hormone therapy more than 10 or 20 years from menopause.”
Use of HT is associated with a significantly increased risk of venous thromboembolism, a risk that increases with time, as does the risk of stroke and pulmonary embolism. Using lower doses or transdermal HT may reduce the risk, but “the lack of comparative randomized controlled trial data limit recommendations.
Transdermal therapy can also be considered for women with metabolic syndrome, hypertriglyceridemia, and fatty liver, since this route avoids first-pass hepatic metabolism.
Breast cancer
The effect of hormone therapy on breast cancer risk is complex and conflicting, noting that breast cancer risk from HT may depend on many factors, including whether progestins are added to estrogen, the dose and duration of HT use, and how HT is administered.
Regarding the use of vaginal estrogen for women who have had breast cancer it’s a data-free zone. Systemic absorption of vaginally dosed estrogen is minimal, but the decision to use vaginal estrogen for a breast cancer survivor who is experiencing genitourinary syndrome of menopause symptoms should always be made in consultation with the woman’s oncologist and in shared decision making with the patient herself.
Bioidentical HT
Unique concerns about safety surround the use of compounded bioidentical hormone therapy.
(To be continued)