HRT Guidelines Favor Individualized Approach to Menopause

Pam Harrison

October 08, 2015

New guidelines for the treatment of menopausal symptoms are giving the green light to hormone-replacement therapy (HRT) for carefully selected women at low risk for cardiovascular disease (CVD) and breast cancer and who are both bothered by their symptoms and are eager to take HRT.

This latest advice was published online October 7, 2015 and will appear in the November issue of the Journal of Clinical Endocrinology and Metabolism.

"We have to be mindful of the individual health concerns of our patients and first ask: 'Is HRT going to be safe for her to take?' " Cynthia Stuenkel, MD, from the University of California, San Diego, and task force chair of the new guidelines, said during a virtual press conference. Women are eligible for HRT if they are under the age of 60 and are no more than 10 years into menopause, Dr Stuenkel emphasized.

Physicians also need to assess a patient's baseline risk for CVD or breast cancer — a high risk for either condition can constitute a contraindication to use of HRT.

Standard CVD risk-assessment scores from organizations such as the American Heart Association can be used to identify women who are at moderate or low risk for CVD events; women falling into both of these categories can be considered for HRT.

For cancer, the National Cancer Institute Breast Cancer Risk Assessment Tool allows physicians to calculate a woman's 5-year risk of invasive breast cancer, while the International Breast Intervention Study calculator predicts a woman's 10-year and lifetime risk.

Vasomotor and Genitourinary Symptoms Warrant Intervention

Menopause symptoms frequently start in the years before the final menstrual period and can last, with unpredictable duration, from a few years to more than 13 years.

The two main symptoms the Endocrine Society's new guidelines specifically target are vasomotor symptoms (hot flushes/flashes/night sweats) and genitourinary symptoms (vaginal dryness or discharge, pain, burning or itching, urinary frequency, recurrent urinary tract infections).

"The most effective therapy [for both sets of symptoms] is HRT," Dr Stuenkel said.

"But we have listed many other nonhormonal and over-the-counter [OTC] options that physicians can use as well, and each of these options can be discussed with patients."

It is less clear whether anxiety, irritability, depression, palpitations, skin dryness, loss of libido, and fatigue can be attributed to menopause, the new guidelines state.

Candidates for HRT can receive estrogen replacement alone if they are without a uterus; if women have a uterus, they require the combination of estrogen plus progestogen to prevent endometrial hyperplasia and cancer.

Additional hormonal options for women with a uterus include estrogen combined with bazedoxifene and tibolone where available.

Other medical options recommended by the Endocrine Society include:

  • Transdermal estrogen therapy by patch, gel, or spray for women who want HRT but who have an increased risk of venous thromboembolism.

  • Selective serotonin-reuptake inhibitors, serotonin/norepinephrine-reuptake inhibitors, gabapentin, or pregabalin are recommended for women who want medication to manage moderate to severe hot flashes but who prefer either not to take HRT or have significant risk factors that make HRT inadvisable.

  • Low-dose vaginal estrogen therapy may be used to treat genitourinary symptom, but even low-dose vaginal estrogen is relatively contraindicated in women with a history of an estrogen-dependent cancer.

Impact of Menopausal Symptoms "Substantial"

"The impact of severe menopausal symptoms on quality of life may be substantial," Dr Stuenkel noted.

In light of this, there are circumstances under which a woman with a history of coronary artery disease or even breast cancer might choose to accept a degree of risk that initially might outweigh the benefits of HRT.

Nevertheless, patients should be fully informed about the risks and benefits of HRT to enable them to make a decision that best balances these risk and benefits, Dr Stuenkel emphasized.

"We in the Endocrine Society were dismayed by the incredible drop-off in the use of HRT [following the Women's Health Initiative study]," she noted.

A 2012 Endocrine Society survey found that 72% of women currently experiencing menopause symptoms had not received any treatment for them.

"And while we don't blame the average clinician for being confused or frustrated by all the contradictory data that have emerged over the past decade, we wanted to take a strong stance to simplify these data and to say that in carefully selected women, HRT will be the most effective therapy we have for menopausal symptoms," Dr Stuenkel added.

"So…the data we present in our guidelines help substantiate why HRT is a reasonable approach for carefully selected women, and physicians should be revisiting this question annually with their patients to discuss their decision regarding HRT and perhaps modify it if other health concerns have arisen in the preceding year."

Stopping HRT an Individual Choice, Too

The guidelines also state that the approach to discontinuation of HRT is an individual choice, too.

Menopausal symptoms and joint pain can recur when HRT is discontinued, and, depending on the severity of the symptoms, women may elect to restart HRT, perhaps at a lower dose, or seek relief with nonhormonal therapies.

"Anecdotally, some women find that a very low dose…maintains adequate symptom relief and well-being and prefer that to complete discontinuation," state the recommendations.

Resources for patients are available at www.menopausemap.org. The Hormone Health Network also offers a digital toolkit for healthcare providers.

Dr Stuenkel had no relevant financial relationships.

J Clin Endocrinol Metab. Published online October 7, 2015. Abstract

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