Download PDF

Guidelines and Recommendations on Hormone Therapy in the Menopause

Amos Pines
Department Medicine "T"
Ichilov Hospital, Tel-Aviv

May 2009

As in other fields of medicine, it would have been easier for the primary practitioner to reach therapeutic decisions based on simple, clear guidelines on postmenopausal hormone therapy (HRT). Unfortunately, this was not possible in the past 6 years, since the results of the WHI study that was published in July 2002 were interpreted in various ways, leading to disruption of the previous consensus that stated "all menopausal women should consider HRT". Following the release of the WHI data, many societies and health organizations claimed that HRT is dangerous, and others recommended the use of hormones only when vasomotor symptoms are severe and cannot be controlled by alternative therapies. The phrase "the smallest dose for the shortest duration" became very popular, bringing this issue ad absurdum, namely prescribing HRT for a few weeks only, and then stopping it because of potential risks. The International Menopause Society was among the few organizations that stood firm against these conceptual changes in practical guidelines, calling for a more scientific and rationale approach to the analysis and implementation of  the WHI data. Luckily, the situation changed again in mid-2007, when WHI investigators admitted that age is a major factor in the benefit-risk balance for hormone users. While cardiovascular events, thrombo-embolism and breast cancer are the main serious adverse reactions of HRT, it seems now that only breast cancer remains a major concern, although still debated. Because of the very low basal incidence of cardiovascular events and thrombo-embolism prior to age 60, the added risks related to HRT in young, healthy postmenopausal women are insignificant or minute. Several high-ranking ObGyn and menopause societies recently updated their recommendations in regard with HRT,  re-confirming and re-legitimizing the use of HRT in symptomatic women while re-assuring the medical community and the public about the safety of treatment in the early menopause.

The following are citations from those 2008 statements:

- The American Association of Clinical Endocrinologists¹ - "... it seems clear from statistical analysis of previous large studies that young women in early menopause not only having no excess cardiovascular risk, but that benefit may be shown in the future. ... given the powerful effects of estrogen therapy in relieving menopausal symptoms, we believe that physicians may safely counsel women to use estrogen therapy for the relief of menopausal symptoms".

- The North American Menopause Society (NAMS)²: "Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both. The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause in previously untreated women".

- The European Menopause and Andropause Society (EMAS)³: "The main indication for HRT use in postmenopausal women remains the relief of menopausal symptoms... Treatment significantly decreases bone loss and risk of osteoporotic fractures... In 50-59-year-old women a window of opportunity for a benefit in cardiovascular disease displays a high plausibility".

- The American College of Obstetrics and Gynecology (ACOG)⁴: "Recent analysis suggest that HT may not increase CHD risk for select populations of women who have experienced menopause recently...Some women may require extended therapy because of persistent symptoms".

- The American Society of Reproductive Medicine (ASRM)⁵: "Hormone therapy is the most effective treatment for moderate to severe vasomotor symptoms... Hormone therapy is not indicated for the primary or secondary prevention of coronary artery disease events. At the same time, perimenopausal women treated with hormones have no increased risk for CHD".

- The International Menopause Society (IMS)⁶: "Achieving good quality of life is a prime target in menopause medicine, which is as important as prevention and treatment of diseases... There is no argue that HRT is the first choice, and the best modality to improve quality of life and sexuality in symptomatic postmenopausal women... The target population for initiation of HRT is usually women up to age 55... HRT initiated at the early postmenopausal period in healthy women is safe... Like all medicines, HRT needs to be used appropriately, but it is essential that women in early menopause who are suffering menopausal symptoms should have the option of using HRT".