Recommendations for Hormonal Treatment: Still Evolving

The North American Menopause Society last issued a Hormone Therapy Position Statement in 2012. Now, they’ve issued a much-anticipated update that helps health care providers determine a course of action for vasomotor symptoms and the genito-urinary syndrome of menopause.

Published in the journalMenopause, the update provides information that can help clinicians choose appropriate hormonal therapies, and explain those therapies to patients.

In this document, hormone therapy means either estrogen therapy or estrogen-progestogen therapy, and the authors differentiate between ET and EPT when significant differences deserve mention. In addition, this document differentiates criteria for hormone therapy in cultural and minority populations, such as those with surgical menopause, early menopause, older age, or primary ovarian insufficiency.

The authors make a key point: clinicians who see menopausal women in their practices need to understand the difference between relative risk, absolute risk, and odds ratios clearly. Relative risk which is also called the risk ratio is the ratio of events that occur in 2 groups. Absolute risk is the difference in risk between 2 groups. Odds ratios measure the association between exposure and outcome, and if an odds ratio is 2 or lower, it is statistically difficult to assign strong validity to the finding if it is derived from observational studies. Odds ratios are most useful if they have been derived from randomized controlled trials.

Hormone therapy is still the most effective means of treating either vasomotor symptoms or the genito-urinary syndrome of menopause. The bottom line finding is that estrogen safety profile is quite good, and many women may benefit from longer durations of therapy. One of the most effective sections of this document describes each hormone therapy’s effects on specific target organs. The charts help health care providers choose an appropriate treatment for patients who have or have had heart disease, breast cancer, stroke, pulmonary embolism, colorectal cancer, or hip fracture.

One recommendation has not changed. Health care providers need to choose the lowest dose that treats symptoms effectively to minimize risk, although treatment duration might be longer than previously recommended. And, dosing should include progestogen to counter systemic estrogen’s effects on the endometrium. This translates to individualizing therapy key for each woman based on her symptoms, and her total health picture.

Health care providers should also remember that in addition to treating vasomotor symptoms, hormone therapy can prevent bone loss and reduce fractures in postmenopausal women. It’s also an effective means by which one can restore genitourinary tract anatomy and treat vulvovaginal atrophy.

Women often have questions about bioidentical hormone therapy, which is usually prepared by a compounding pharmacy. This document explains that bioidentical hormones are similar to endogenous hormones. The authors report that compounded bioidentical hormone therapy has minimal government oversight, and healthcare providers need to be aware that this can be a safety concern. These hormones are dosed based on salivary hormone testing, a procedure that has been noted to be unreliable. Clinicians who choose to use bioidentical hormones should document carefully indicating why they are using these products, including an allergy to available products or the need for formulation that is not yet FDA approved.

This document, which is 26 pages in length, also covers special populations in many different conditions. It is comprehensive in its detail, noting conditions in which evidence indicates that hormone therapy will help and also documenting when evidence indicates that hormone therapy will probably not help.

The authors don’t deny that there is still a considerable amount of controversy surrounding hormones therapy. They suggest that health care providers replace the concept of “lowest dose for the shortest period of time” with “appropriate dose, duration, regimen, and route of administration.”

Reference

The 2017 hormone therapy position statement of The North American Menopause Society.Menopause. 2018;25(11):1362-1387.