Time to take the fear out of hormone therapy

(Conclusion)

The lack of regulation and monitoring, together with lax labeling requirements, are areas of concern. Accurate dosing may not be occurring, and data are lacking to support safety and efficacy of compounded bioidentical products. Neither is there evidence to support routine testing of serum or salivary hormone levels.

Symptom relief

For isolated symptoms of genitourinary syndrome of menopause, low-dose vaginal preparations are safe and effective. For women who are symptomatic, use of either low-dose vaginal estrogen or systemic HT increases sexual function scores; however, hormone therapy is not recommended as the sole treatment of other sexual function problems, such as diminished libido, though it can be a useful adjunct.

 Hormone therapy is the most effective treatment for hot flashes, and using HT improves sleep quality and duration in women with bothersome night time hot flashes.

Fracture prevention

Data from the Women’s Health Initiative showed a highly significant 33 percent reduction in hip fractures for women using both estrogen alone and estrogen with progestogen.

That seems to get forgotten. Though HT’s osteoporosis and fracture prevention effects stop when HT is discontinued, there’s no evidence of elevated fracture risk above baseline in women who have used HT and then stopped.

Younger women may need higher doses to protect bones, but make sure you get adequate endometrial protection if you do that.

Unapproved uses

Hormone therapy is not recommended at any age to prevent or treat cognition or dementia, citing a lack of data to support its use for these reasons. Observational data may show some reduction in risk of Alzheimer’s disease in women who use HT at younger ages or soon after menopause.

Though HT users have a reduced risk of developing type 2 diabetes, diabetes prevention is not a Food and Drug Administration-approved indication for HT. Abdominal fat accumulation weight gain may be reduced by HT as well.

Similarly, there are no data to support the use of HT for the treatment of clinical depression. Perimenopausal – but not postmenopausal – women may see some benefit from estrogen therapy; progestins may actually contribute to mood disturbance.

Special populations

Systemic hormone therapy is not recommended for survivors of breast cancer. Any consideration for systemic HT in this population should include the oncologist, and be entertained only after other nonhormonal options have been tried.

Women with a family history of breast or ovarian cancer, or with the  BRCA mutation, do not appear to have their risk increased by the use of HT, though the ovarian cancer data are limited and observational.

The NAMS position statement also addresses the use of HT in other special populations, including survivors of other cancers and women who have primary ovarian insufficiency or early menopause, BRCA-positive women who have undergone oophorectomy, and those over age 65 years.

The recommendation to routinely discontinue systemic hormone therapy after age 65 is not supported by data. I would tell you that there’s a lack of good data about prolonged duration. What I tell patients is, “we really are in another data-free zone.” It recommends an individualized approach that balances benefits and risks and includes ongoing surveillance.

The new message

So what do I want us to do? I want us to change the message. Rather than advocating for HT to be used in “the lowest dose, for the shortest period of time, it was said the new message should be for women to use “appropriate hormone therapy to meet their treatment goals.”

The bottom line? After accounting for women who should avoid HT for specific contraindications, benefits are likely to outweigh risks for symptomatic women who initiate hormone therapy when aged younger than 60 years and within 10 years of menopause.