Individualizing Hormone Therapy to Minimize Risk

Accurate Assessment of Risks and Benefits

Donna Shoupe

Disclosures

Women's Health. 2011;7(4):475-485. 

In This Article

Strategies to Minimize Risk

Many women may want the benefits associated with hormone therapy including protection from cardiovascular disease, osteoporosis and fracture, urogenital atrophy, skin atrophy and dementia. Minimizing the risks of taking hormone therapy for these women is an important consideration.

  • Timing hormone therapy: when started in women under 60 years or within 10 years of their menopause, is not associated with an increased risk of heart disease and many studies show that estrogen therapy actually protects the coronary vessels. Continuing therapy, at least through 65 years of age, appears to continue this protection.[2]

  • Minimizing the dose: using the lowest effective dose for menopausal symptoms lowers the risk of side effects and bleeding problems. Low-dose therapy is also associated with beneficial effects on bone metabolism and vaginal tissue.

  • Delivery method may be important: estrogen can be administered by patch, gel, mist, vaginal cream, vaginal suppository or vaginal rings. Use of these non-oral delivery methods minimizes the effect of estrogen on hepatic proteins. The non-oral delivery methods are recommended for women with suspected or known cardiovascular disease, clotting abnormalities, thromboembolic history, pronounced obesity, prolonged hypertension or diabetes, advanced age or prolonged immobilization. Minor differences among these transdermal estrogen preparations or among the many oral estrogen preparations is not the focus of this article.

  • Adding a progestin: for women who have not had a hysterectomy, addition of a progestin to estrogen therapy is necessary to protect the endometrium from overstimulation. One of the advantages of using a low-dose estrogen product is that it allows for minimizing the dose of the progestin. The combination products on the market contain balanced levels of estrogen and progestin and generally minimize uterine bleeding. Some clinicians and patients prefer to select separate estrogen and progestin products. There are a large variety of progestins that can be used in this manner and differences in the progestins may offer clinical advantages. In general, these differences are minimal when a low-dose option is used and are not the focus of this article.

  • Consider high risk factors: women with a personal history of breast cancer or active liver disease are generally advised to avoid hormone therapy. Those with heart disease, a history of blood clots, advanced age, longstanding diabetes, longstanding hypertension or those with prolonged immobilization should fully evaluate a risk–benefit profile before initiating hormone therapy and consider low-dose transdermal therapy.

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