AACE/ACE Now Update Guidelines for Menopause Treatment

Pam Harrison

July 19, 2017

Yet another position statement on the treatment of menopausal symptoms is urging physicians to individualize their approach to women seeking relief from the consequences of low estrogen levels, including hot flushes and genitourinary problems.

The latest American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) position statement was published in the July issue of Endocrine Practice.

"AACE feels it is important to emphasize that one size doesn't fit all when it comes to treating women with menopause," Rhonda Cobin, MD, past president of AACE and a member of its reproductive endocrinology scientific committee, said in a statement.

"Hormone-replacement therapy [HRT] must be individualized based on a woman's age, time of onset of menopause, and other cardiovascular, metabolic, and genetic factors," she added.

The AACE committee notes that no recommendations from its previous guidelines in 2011 have been reversed or changed.

However, "new information available from randomized clinical trials and epidemiologic studies reported after 2011 was critically reviewed," committee members state.

Among the new recommendations is a suggestion that transdermal rather than oral estrogen might be considered if physicians are concerned about a patient's thrombotic risk. Transdermal HRT might also reduce the risk of stroke and coronary artery disease, they indicate.

And "when the use of progesterone is necessary, micronized progesterone is considered the safer alternative," committee members note.

Similarly, women seeking relief from menopausal symptoms may benefit from the use of selective serotonin reuptake inhibitors (SSRIs) and possibly other nonhormonal agents if HRT is judged to be too great a risk for an individual woman.

Specific Recommendations for Women With Breast Cancer

Of note, however, the committee cautions that certain SSRIs are contraindicated in patients taking tamoxifen for the prevention of breast cancer recurrence, a recommendation that supports management practices endorsed by the Comité de l'Évolution des Pratique Oncologie (CEPO) in Quebec.

Physicians should avoid the use of paroxetine and fluoxetine in women on tamoxifen because these SSRIs may reduce the efficacy of the anticancer treatment, as CEPO observes.

Rather, CEPO suggests that venlafaxine, citalopram, clonidine, gabapentin, and pregabalin may be used for the treatment of hot flashes in breast cancer patients taking tamoxifen.

Venlafaxine, paroxetine, citalopram, clonidine, gabapentin, and pregabalin may also be considered for the treatment of hot flashes in breast cancer patients not taking tamoxifen.

The AACE committee also notes that women who are at high risk of or have had breast cancer should not use black cohosh for the treatment of menopausal symptoms, a recommendation again supported by CEPO.

No Evidence to Support Bioidentical Compounded HRT

The AACE/ACE committee does not endorse the use of bioidentical hormones, the same recommendation it made in its 2011 position statement.

As the statement authors note, there is no evidence supporting manufacturers' claims that bioidentical products are any safer than their approved HRT counterparts, and there is a risk that patients will get either greater or lesser amounts of the biologically active hormone as there is often a lack of consistency in the content of compounded products.

Common compounded bioidentical hormones include triestrogens (estriol, estrone, estradiol in an 8:1:1 ratio), biestrogen (estriol, estradiol in a 4:1 or 9:1 ratio), estriol/progesterone (2–8 mg/day plus 100–200 mg/day), testosterone, and dehydroepiandrosterone.

Individualize HRT Therapy

Unlike the recently published position paper on HRT by the North American Menopause Society (NAMS), however, the AACE/ACE position paper does not specifically caution against introducing HRT in women who are 10 or more years out from the menopause or those 60 years of age or older, for whom the risk of treatment may outweigh the benefits.

However, the committee did indicate that HRT is less likely to be harmful if introduced early on in the menopause rather than if used later on.

Nor does the AACE committee recommend physicians use HRT to prevent diabetes; in women with diabetes, the committee cautions that HRT be prescribed only after carefully considering its risk given the patient's age, as well as the presence of metabolic and cardiovascular risk factors.

"The updated position statement on menopause demonstrates AACE's commitment to individualizing our guidelines as much as current science permits for the betterment of patient care," Mack Harrell, MD, president of ACE said in a statement.

The authors have reported no relevant financial relationships.

Endo Pract. 2017;23:869-880. Article

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