Hormone Replacement: Timing Is Everything, Say New Guidelines

Jennifer Garcia

March 14, 2013

Authors of a new consensus statement on menopausal hormone therapy (MHT) conclude that it is the most effective treatment for menopausal symptoms and that benefits are likely to outweigh the risks if it is prescribed before the age of 60 years or within 10 years after menopause. The statement was published in the April issue of Climacteric and also in Maturitas.

The brief consensus was published on behalf of 7 major international and US societies working in menopause and women's health and summarizes the state of the science on MHT use.

Overall, Tobie J. de Villiers, MBChB, from MediClinic Panorama and Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa, and colleagues conclude that the benefits of MHT generally outweigh the risks if used for women younger than 60 years or within 10 years after menopause. Dose and duration should be individualized, and personal risk factors such as "the risk of venous thromboembolism, stroke, ischemic heart disease and breast cancer" should guide use of MHT.

Key Conclusions

  • The benefits of MHT outweigh the risks for the treatment of symptoms associated with menopause if prescribed before the age of 60 years or within 10 years after menopause.

  • MHT may prevent osteoporosis-related fractures in at-risk women before the age of 60 years or within 10 years after menopause.

  • Review of randomized clinical trials and observational data shows that MHT using standard-dose monotherapy with estrogen may decrease coronary heart disease and all-cause mortality in women younger than 60 years and within 10 years of menopause.

  • Oral MHT increases the risk for venous thromboembolism and ischemic stroke, but the absolute risk is rare in women younger than 60 years.

  • Increased risk for breast cancer may be a concern with combination MHT using estrogen and a progestogen and may be related to duration of use. The risk is small and decreases after treatment is discontinued.

  • Use of custom-compounded bioidentical hormone therapy is not recommended.

  • MHT should not be used in women who have a history of breast cancer.

"The primary indication for using oral MHT is for relief of menopausal hot flashes," Heidi D. Nelson MD, MPH, research professor in the Department of Medical Informatics and Clinical Epidemiology and the Department Medicine at Oregon Health & Science University in Portland, told Medscape Medical News. "Its use should be at the lowest dose and shortest duration necessary to improve symptoms and quality of life, and should be individualized. These points of agreement are clinically relevant to many women."

She continued, "[The authors'] statement about estrogen-alone MHT decreasing coronary heart disease and all-cause mortality in women younger than 60 and within 10 years of menopause is not based on strong evidence. They qualify this statement by phrasing it as 'may decrease,' but this could be misleading. However, it is reassuring that MHT does not increase heart disease in this age group."

The authors of the report conclude that these recommendations will be reviewed as new data become available.

The meeting of the consensus panel was supported by the participating societies only. The authors and Dr. Nelson have disclosed no relevant financial relationships.

Climacteric. 2013;16:203-204.

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