By positions I do not mean contortions in a physical sense, although in the gynecologic world the position regarding hormone therapy has created splits and pirouettes among physicians and their menopausal patients. But lo and behold a new position statement by the mavens of menopause, the North American Menopause Society (NAMS to you and me), has been issued and published in the journal “Menopause”. It is 15 pages long and includes a list of 173 references. I’ll spare you the details but try to rephrase the important parts of the article and its summary.
NAMS states that the decision to prescribe hormone therapy (HT) should be made based on a woman’s health, her symptoms, her preferences for quality of life as well as her personal risk factors. (Well, that has certainly not changed from what most of us told our patients in the past.)
They go on to state that once started, continuation is dependent on whether estrogen only or estrogen and a progestin are given. And severity of symptoms should be considered in any decision to terminate hormone therapy. In general they feel it’s “safe” ( the multiple authors use the term “a more favorable benefit-risk profile”) if estrogen therapy without a progestin (ET) is given for 7 years (and perhaps longer depending on the studies cited). But remember we can give estrogen without a progestin only if a woman has had a hysterectomy. If she has not had surgery with removal of her uterus a progestin should be given to prevent endometrial (uterine lining) cancer. In this later instance (i.e. no previous hysterectomy) duration of use of HT (estrogen plus a progestin) should probably be more limited due to the increased risk of breast cancer after 3 to 5 years.
The NAMS statement concluded the estrogen therapy is the most effective treatment of symptoms of vulvae and vaginal atrophy. They advise low-dose, vaginal local estrogen when the only symptom is vaginal atrophy (think dryness and pain with intercourse)…and then state that when this is the only form of estrogen used, there is no need for concomitant progestin.
Women with premature or early menopause who have no contraindications (clots, breast or endometrial cancer) can, and probably should, use HT at least until the median age of natural menopause (age 51). After that time, the same decisions should be made as for women going through natural menopause.
No increase in breast cancer risk was observed in the Women’s Health Initiative with use of estrogen in breast cancer survivors but… they pointed out that there is a lack of good data and one randomized control study found an increase in breast cancer recurrences. So they don’t recommend its use.
Finally they stated that both transdermal estrogen ( patches, creams and sprays) and low dose oral estrogen have been associated with lower risks of deep vein clots and stroke than that found with standard doses or oral estrogen, But they wouldn’t take the final step and commit to this, proclaiming that sufficient randomized studies to endorse this have not as yet been completed.
And finally the NAMS position ends with the statement that there is a “growing body of evidence that HT formulation, route of administration , and timing of therapy produce different results” In other words one size and one type does not fit all.
Starting hormone therapy, the type, route of administration, dose and duration of use remain important issues that all women going through menopause should discuss with their physicians. We now have more studies and guidelines to help you with these hormonal decisions.