COMMENTARY

What to Know About the NAMS Updated Position on Hormone Therapy

Andrew M. Kaunitz, MD

Disclosures

July 17, 2017

Hello. I am Andrew Kaunitz, professor and associate chair in the Department of Obstetrics and Gynecology at the University of Florida College of Medicine in Jacksonville. Today I'd like to discuss new guidance from the North American Menopause Society (NAMS) regarding hormone therapy.

This June, NAMS released its 2017 updated Position Statement regarding hormone therapy (HT). This document is available at no charge at the NAMS website, menopause.org.[1] A disclosure: I served on the Position Statement Writing Group and currently serve on the NAMS Board of Trustees.

A fundamental message of this evidence-based statement is that systemic HT represents an appropriate choice for symptomatic women in their 50s or within 10 years of the onset of menopause. Although the new document provides detailed guidance for patient groups, ranging from those in early menopause to BRCA mutation carriers, in this video I will focus on its expanded recommendations regarding extended-duration HT use.

The 2017 NAMS guidance states: "Hormone therapy does not need to be routinely discontinued in women aged older than 60 or 65 years and can be considered for continuation beyond age 65 years for persistent VMS, QOL issues, or prevention of osteoporosis after appropriate evaluation and counseling of benefits and risks."[1]

The median duration of bothersome hot flashes is more than 10 years, underscoring that many women who initiate HT soon after the onset of menopause to treat symptoms will face decisions regarding long-term HT use.[2] However, the paucity of published data addressing benefits and risks of such use makes continuation in women older than age 65 controversial.

A second indication for extended-duration use of systemic HT addresses women, for example, with a low body mass index who have outgrown their hot flashes but are at elevated risk for osteoporosis and wish to continue HT to prevent fractures.[3] When HT is continued in older menopausal women solely for osteoporosis prevention, lower-than-standard doses are appropriate. Examples of lower doses of estrogen include estradiol 0.5-mg tablets, conjugated equine estrogen 0.3- or 0.45-mg tablets, and patches releasing 0.014, 0.025, or 0.0375 mg of estradiol.

The Position Statement details that in women with an intact uterus, use of estrogen-progestin therapy appears to increase the risk for breast cancer. Accordingly, the benefit-risk ratio for extended-use estrogen-progestin therapy is less favorable than for estrogen-only therapy.

The Position Statement also details that in contrast with oral estrogen, transdermal estradiol may not elevate risk for venous thrombosis or stroke. Because age also represents a risk factor for venous thrombosis and stroke, use of 0.05-mg or lower-dose transdermal estrogen may be safer than oral estrogen in older menopausal women.

In women using systemic HT for an extended duration, it is important to discuss HT benefits and risks with our patients on an annual basis, focusing on their individual health profile.

The final issue I will address relates to insurance carriers denying coverage for systemic HT in women older than age 65. These letters often cite the Beers list from the American Geriatrics Society. The NAMS Position Statement indicates: "...the Beers Criteria recommendation to routinely discontinue systemic HT after age 65 is not supported by data."[1] Viewers may find this statement useful when responding to notices of denial.

In summary, this updated NAMS statement provides clarification and reassurance for clinicians and menopausal women considering initiation and extended use of HT. Thank you for the privilege of your time. I am Andrew Kaunitz.

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