Hormone Therapy for Menopausal Women in the Primary Care Setting

Kyleen E. Swords, MS, FNP-BC


Journal for Nurse Practitioners. 2017;13(8):562-569. 

In This Article

Debunking the Myth Behind MHT

If lifestyle changes have been implemented for 3 months with minimal or no relief of symptoms, MHT may be an appropriate next step in a provider's approach to treatment.[8] MHT should be offered to women who are bothered by moderate to severe VMSs or women who do not experience relief with nonhormonal methods.[7] MHT is the most effective option in treating menopausal symptoms because through its replacement of estrogen back into a woman's body, the source of the symptoms is physiologically reversed.[4] However, many providers and patients are resistant to the implementation of MHT because of reports of adverse outcomes revealed in research studies, most significantly in the Women's Health Initiative (WHI).[2]

Before the year 2000, the majority of research and information on MHT was based on observational studies for the treatment of menopausal symptoms. The WHI, supported by the Department of Health and Human Services, the National Institutes of Health, and the National Heart Lung and Blood Institute, conducted a randomized controlled study aimed at better understanding the effects of MHT on a woman's development of chronic disease, with a primary focus on cardiovascular health, bone health, and risk of breast cancer. The study was divided into 3 separate arms: estrogen therapy alone, estrogen-progestin therapy, and a control group of no hormonal therapy. The study was stopped prematurely (2002 for the estrogen-progestin arm and 2004 for the estrogen-only arm) because of the adverse effects associated with the use of MHT.[13] Specifically, the estrogen-progestin arm reported an increase in the risk of breast cancer, as well as an increased incidence of stroke and coronary heart disease.[13] The estrogen-only arm of the study was ended early because of the increased incidence of stroke.[13] After the publication of these findings, patients' use of MHT and providers' willingness to recommend and prescribe the therapy decreased by an overwhelming 70% to 80%.[1,2,14]

Although the results highlighted the adverse effects of MHT, it is important to note that the study was performed on women at an average age of 63 years (postmenopausal). The purpose of the study was to look at the beneficial effect of MHT on the prevention of chronic disease, not on relief from VMSs.[9,13] Although the results of the study accentuated the risks of MHT, reanalysis of the study allowed for a further understanding of MHT and provided best practice evidence for when to initiate therapy and how to manage patients on MHT.[1] For example, in the estrogen-only arm of the study, there was a reduction of the risk of CVD in women who initiated the therapy at an age closer to menopause, and the risk of stroke was found to be much smaller for women in the perimenopausal period, as opposed to those who began therapy in the postmenopausal period.[13] This finding is further supported by the more recent Kronos Early Estrogen Prevention Study, which is a randomized controlled trial focused on MHT effects on symptom management in women going through the menopausal transition (ages 42–58, with an average age of 52).[15,16] Additionally, the WHI revealed that women initiating estrogen-progestin therapy close to menopause were found to be at a higher risk for breast cancer. Therefore, it is important that women on combined MHT should have well-documented follow-up of mammograms and breast examinations. Although the WHI reported important MHT-related risks, the study data showed that MHT can be an appropriate therapy for women for a limited period of time when the benefits outweigh the risks.[13] The "take-home" message from the WHI is that the decision for treatment should be individualized to the patient and specifically focus on a woman's individual risk factors, age of initiation of therapy, and appropriate follow-up.