COMMENTARY

Which Women Are the Best Candidates for HRT?

JoAnn E. Manson, MD, DrPH

Disclosures

April 10, 2015

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Hi. I'm Dr JoAnn Manson. I gave a talk recently at The Endocrine Society's 2015 Annual Meeting on the subject of personalized menopause management,[1] discussing some of the clinical factors and biomarker data that help to inform clinical decision-making about the use of hormone therapy.

We now have a critical mass of research suggesting that there are some very important factors that help with risk stratification to identify the women who are the most appropriate candidates for hormone therapy. We know that one size does not fit all, and some but not all women are good candidates for hormone therapy.

Assuming a woman has moderate-to-severe hot flashes and night sweats, it seems that a really key factor is her age. Is she below the age of 60 years? Is she within 10 years of the onset of menopause when she initiates hormone therapy? Does she have a relatively low risk for cardiovascular disease at baseline?

We found that some of the biomarkers, such as LDL cholesterol and total cholesterol, HDL ratio, and metabolic syndrome factors—increased blood pressure, a high blood sugar level, excess body fat around the waist, and abnormal cholesterol levels, occurring together[2] —do modify the risk for heart disease with hormone therapy. Women who have high risk factor levels and tend to be at high baseline risk for cardiovascular disease do tend to do worse on hormone therapy than women who are at relatively low risk.

We do recommend using a cardiovascular risk score calculator such as MenoPro,[3] a mobile app that's free and downloadable. It can be used to calculate risk for atherosclerotic cardiovascular disease (ASCVD) with the American College of Cardiology's and the American Heart Association's ASCVD Risk Estimator.[4] The score can be used to gauge risk over the next 10 years. That can help identify women who are in a low or moderate risk category and distinguish them from women in a high risk category.

There are also risk factors for breast cancer that may make a woman a suboptimal candidate for hormone therapy. If a woman does have a high Gail[5] risk score, that would be another factor to consider.

During my recent talk, I presented some preliminary data from the ELITE trial,[6] the Early versus Late Intervention Trial with Estradiol. Howard Hodis is the lead investigator. Those data really do provide strong evidence for the timing hypothesis: Women who initiate hormone therapy early—within 6 years after the onset of menopause—have some slowing of the progression of atherosclerosis, whereas women initiating more than a decade past menopause do not have that slowing, shown by carotid intima-media thickness measurements.

Overall, a lot of information is now available to aid with risk stratification. That information helps to identify the women most likely to be good candidates for hormone therapy, to try to achieve the benefits of symptom reduction while minimizing the risks of treatment. For women who are not candidates, there are now many nonhormonal options.

Thanks so much for your attention. Please add your comments below.

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