COMMENTARY

Menopausal Hormone Therapy: 2010 Guidelines From NAMS and Endocrine Society

JoAnn E. Manson, MD, DrPH

Disclosures

August 04, 2010

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Hi, I'm JoAnn Manson, Professor of Medicine at Harvard Medical School and Chief of the Division of Preventive Medicine at Brigham and Women's Hospital. I would like to talk with you today about 2 recent reports on menopausal hormone therapy. One of these reports was a physician statement from the North American Menopause Society (NAMS) published in the journal Menopause, and the second is a scientific statement from The Endocrine Society published in the Journal of Clinical Endocrinology and Metabolism; both were published in recent months.

These 2 reports provide perspective and interpretation of recent findings on hormone therapy and how they can inform clinical decision making. Overall the reports are remarkably congruent in terms of their interpretation of the recent findings. There are at least 3 areas where the reports find common ground. One of the areas is that they both endorse the concept of the timing hypothesis, which suggests that a woman's age and time since onset of menopause influence her health outcomes on hormone therapy and her overall benefit-risk ratio. This seems to be particularly true for coronary events and all-cause mortality.

The second area of common ground is the emphasis on absolute risk and the background risk for clinical events in a woman, which is heavily influenced by a woman's age and time since menopause. A woman who has a low absolute risk for coronary disease, stroke, various cancers, and all-cause mortality is less likely to have adverse events from hormone therapy and more likely to have a favorable tradeoff in terms of the effects she'll have. Therefore, she will be more likely to have an indication for hormone therapy use because she is recently menopausal and may have hot flashes and night sweats, and will be less likely in absolute terms to have a stroke, clinical event, or adverse event related to hormone therapy. This would lead to a more favorable benefit-risk ratio.

Another area of common ground is that both reports recommend that hormone therapy use be limited to the management/treatment of menopausal symptoms and not be used for chronic disease prevention. This is particularly important in regard to the findings from the post-stopping period of the estrogen-plus-progesterone trial that showed several cancers increased, including lung cancer, which became apparent after stopping hormone therapy, and overall the benefit-risk ratio became less favorable after stopping. It's clear that hormone therapy continues to have a clinical role in the management of menopausal symptoms but not for prevention of chronic disease outcomes, and that's where the tradeoff may be less favorable, especially with long-term use.

Overall we need more research on hormone therapy in recently menopausal women. We need to know more about the role of the dose of hormone therapy; lower doses are now being used. We also need to know more about different routes of delivery (eg, the transdermal option), and also the effect of bioidentical hormones on the benefit-to-risk-ratio: Is there really any evidence that they are more effective or safer than conventional hormone therapy?

These recent reports do help to inform clinical decision making about hormone therapy and are very useful and helpful in providing us perspective on the recent evidence. Thank you for listening. I'm JoAnn Manson.

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