Perimenopausal HT Supported by New NAMS Guidelines

Laurie Barclay, MD

February 27, 2012

February 27, 2012 — The North American Menopause Society (NAMS) supports starting hormone therapy (HT) around the time of menopause to treat menopause-related symptoms and to prevent osteoporosis in women at high risk for fracture, according to a position statement published online February 27 in Menopause: The Journal of The North American Menopause Society.

"This position statement aimed to update the evidence-based position statement published by [NAMS] in 2010 regarding recommendations for [HT] for postmenopausal women," write cochair Margery L.S. Gass, MD, and colleagues from the NAMS 2012 HT Position Statement Advisory Panel."This updated position statement further distinguishes the emerging differences in the therapeutic benefit-risk ratio between estrogen therapy (ET) and combined estrogen-progestogen therapy (EPT) at various ages and time intervals since menopause onset."

Highlights of the specific recommendations include the following:

  • The most effective treatment for menopausal vasomotor symptoms and associated quality of life is ET or EPT.

  • Recommended duration of therapy differs for EPT in women with a uterus and for ET in women who have had a hysterectomy.

  • Heightened risk for breast cancer associated with more than 3 to 5 years of EPT use limits the duration of safe EPT use. For ET, the benefit–risk profile is more favorable. Because risk for breast cancer does not appear to increase during an average of 7 years of ET use, there is more flexibility in duration of ET treatment.

  • HT use is associated with a lower fracture risk, but a higher risk for ischemic stroke, venous thromboembolism, and ovarian cancer.

  • Compared with ET, EPT is associated with a higher risk for coronary artery disease, and potentially of ovarian cancer, than ET.

  • The decision to use HT should still be individualized and patient-specific, based on the patient's priorities regarding health and quality of life, as well as on specific risk factors for thrombosis, cardiovascular disease, stroke, and breast cancer.

  • NAMS recommends EPT for relief of hot flashes in women with a uterus, so that the progestogen component will protect the uterine lining from the carcinogenic effects of estrogen alone.

  • For women whose symptoms are limited to vaginal dryness or dyspareunia, NAMS recommends low-dose vaginal ET.

  • Among healthy women younger than 60 years or within 10 years of menopause, neither ET nor EPT use is associated with increased risk for cardiovascular disease. Although stroke risk may be increased, it is still a rare occurrence among women younger than 60 years.

  • Women with premature or early menopause and no contraindications to HT may use HT until age 51 years, which is the average age of natural menopause, or longer if needed to control symptoms.

  • Safety data are lacking to support HT use in breast cancer survivors.

  • Compared with standard doses of oral estrogen, transdermal ET and low-dose oral ET may have reduced risks for thrombosis and stroke. However, these apparent benefits need to be confirmed in randomized trials.

  • Future studies should investigate patient-specific effects of ET and EPT.

"Current evidence supports the use of HT for perimenopausal and postmenopausal women when the balance of potential benefits and risks is favorable for the individual woman," the statement authors write.

"Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms and to prevent osteoporosis in women at high risk of fracture. The more favorable benefit-risk ratio for ET allows more flexibility in extending the duration of use compared with EPT, where the earlier appearance of increased breast cancer risk precludes a recommendation for use beyond 3 to 5 years."

The financial disclosures of the coauthors are extensive and are listed with the text of the article.

Menopause. 2012;19:257-271. Abstract


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