Hormone Therapy for Menopausal Women in the Primary Care Setting

Kyleen E. Swords, MS, FNP-BC

Disclosures

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

In This Article

Indications for MHT

Menopausal symptoms typically are present and are considered at their worst in the 2-year window around the start of menopause; however, some women can suffer from symptoms for an extended period of time of about 10 years or more.[4,8] Hot flashes are rapid fluctuations in body temperature that can cause discomfort, flushing, and a rapid heartbeat.[3,4] Hot flashes are not only uncomfortable but can also lead to sleep deprivation and embarrassment and affect a woman's quality of life.[3] Vaginal atrophy, another common reason perimenopausal women seek care, is a direct result of decreased estrogen in the body causing dryness in the vaginal canal, leading to dyspareunia and an increase in urinary tract infections.[12]

Initiating a woman on MHT requires a full assessment of a patient's past health history, family history, and current health history before she can be considered a candidate for treatment. Based on findings from the WHI, women who are < 60 years old or < 10 years from menopause are considered appropriate patients for initiating MHT.[5] This recommendation has been further supported by the Study of Women Across the Nation, an ongoing observational study aimed at better understanding the physical and psychological changes women undergo during the menopausal transition (women ages 42–52).[16–18] In regard to past health history, it is important to consider a woman's personal history of CVD, cancer history, surgical history, and smoking history because each of these areas poses potential risks for a woman on MHT. Additionally, a detailed assessment of a woman's family history for both CVD and breast cancer contributes to her overall risk assessment. The Endocrine Society recommends calculating an individual's cardiac disease risk, with the American Academy of Cardiology/American Heart Association's 10-year CVD risk calculator, as well as breast cancer risk, with the 5-year National Cancer Institute risk assessment, to establish individualized risks for the development of these diseases as part of the decision to initiate MHT; however, risk cutoffs have not been established, and these calculations should act as a supplement to the woman's overall risk assessment.[5]

The most ideal time to initiate MHT is during the perimenopausal period because it has been shown by the WHI, Kronos Early Estrogen Prevention Study, and Study of Women Across the Nation studies that beginning therapy at this time and continuing throughout the full transition to menopause is associated with the lowest amount of risk and the most benefits to the patient.[1,15,18] To determine if a woman is in this transitional period, it is important to ascertain the patient's VMS history, including when the symptoms started, how often they occur, and which symptoms are the most problematic. The date of the last menstrual period will help to determine what stage of menopause the patient is in and whether or not it is appropriate for her to initiate MHT. It is also important to assess a woman's use of alternative, nonhormonal treatments for these symptoms.[7]

Before initiating MHT, a thorough physical examination should be conducted. Blood pressure reading, auscultation of the heart, and assessment of the peripheral vascular system by visual inspection (unless further workup is indicated) are important components in the examination to confirm a patient is cardiovascularly fit before the initiation of MHT.[8] Additionally, breast examinations and mammograms should be upto-date. Finally, a speculum and bimanual examination will help a provider assess for vaginal atrophy, any undiagnosed vaginal bleeding, and cervical pathology. The presence of undiagnosed vaginal bleeding is a contraindication to MHT, as well as current thromboembolic disease, myocardial infarction, endometrial cancer, and active breast cancer.[5,6] Table 2 is a list of common conditions that are contraindications to MHT or conditions in which special consideration must be used before MHT initiation.

Laboratory tests may be included as an additional step in a woman's MHT workup; however, it is not a requirement before the initiation of therapy. Folliclestimulating hormone, luteinizing hormone, and estradiol levels can be assessed when a woman is in the perimenopausal stage. As menopause progresses, the follicle-stimulating hormone and luteinizing hormone levels rise, and the estradiol level decreases. The absence of these changes does not preclude a woman from symptoms or from initiating MHT and therefore should only act as a supplement to a provider's decision-making process.[4]

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