The Latest Info on Menopausal Hormone Therapy (MHT)
I just returned from Orlando where I attended the 2016 Annual Meeting of the North American Menopause Society (NAMS). I know what you are thinking, a conference about the menopausal vagina – must have been so dry! Quite the contrary!
Having just read the 2016 Revised Global Consensus Statement on Menopausal Hormone Therapy (MHT) which was published in Climacteric June 2016, I was excited to attend the presentation of the 2016 Clinical Guidelines and Position Statement for NAMS and hear the panel discussions amongst the experts as well as the NAMS members questions and comments.
This new revision has been endorsed by The International Menopause Society, The North American Menopause Society, The Endocrine Society, The European Menopause and Andropause Society, The Asia Pacific Menopause Federation, The International Osteoporosis Foundation and The Federation of Latin American Menopause Societies. These are not to be confused with the Skull and Bones Society which is clearly more secret and the rituals probably less hot!
I spoke with JoAnn V. Pinkerton, MD, NCMP, Executive Director, The North American Menopause Society for some additional clarity. According to Pinkerton, “The global consensus on menopausal hormone therapy comes from leading menopause societies in the world to provide guidelines about the use of hormone therapy, an area that has troubled both health care providers and women.”
The first Global Consensus statement was published in 2013. Pinkerton gave me a quick synopsis of the changes made since 2013, “The most significant changes include the potential benefits for women before the age of 60 or within 10 years of menopause for relief of hot flashes and prevention of bone loss, the inclusion of differences between estrogen alone and estrogen with progestogen therapy, the effects of hormone therapy on mood, the use of vaginal estrogen in selected women with breast cancer after discussion with oncology, and that discussions of dose and duration should take into account benefits and risks for individual women regarding starting, continuing or discontinuing hormone therapy.”
The consensus statement explains that MHT has protective benefits for bone health, vaginal health, VSM prevention, joint and muscle pain, mood changes, coronary heart disease, and sleep disturbances for women under the age of 60 or within 10 years of menopause. So why would 60+-year-old women want to go off of their MHT when it is so beneficial and the risk of breast cancer is so small? Of course, I always ask the same question – hoping to get a black and white answer one day! Hey, a gal can hope!!!
Here is Dr. Pinkerton’s response:
“Decisions about the duration of HT require individualization, including consideration of personal preferences, balancing potential ongoing benefits and risks, and decisions to continue hormone therapy for preventive and/or quality-of-life purposes. Decisions should take into account the woman’s risk (personal or familial) of breast cancer, coronary heart disease, blood clots or stroke.
There is less concern about the duration of estrogen-only use, as a reduced risk of breast cancer was seen with conjugated estrogens in the Women’s Health Initiative Study at 7 years, although some studies suggest an increased risk with longer durations of use. Women on estrogen and progestogen need to know about the potential increased (rare) risk of breast cancer (< 1 additional case per 1,000 women per year of use) after 4 to 5 years of standard dose in the CEE/medroxyprogesterone acetate arm of the WHI.
More favorable benefits have been seen in coronary heart disease and all –cause mortality for women who start hormone therapy closer to menopause, with more concern for those women who start it after age 60 or more than 10 years from menopause.
Extended duration may be indicated for the prevention of bone loss and fracture in selected women, recognizing that rapid bone loss is seen on discontinuation of hormone therapy.
For all women, discussions about continuing hormone therapy require individual consideration of benefits and risk of continuing or discontinuing and with ongoing surveillance, recognizing a lack of clear data.”
Dr. Pinkerton listed the key points of IMS global consensus with which NAMS is in agreement. You might want print and re-read this info to fully digest it:
- Hormone therapy is the most effective treatment for vasomotor symptoms (hot flashes, night sweats, sleep disruption) associated with menopause at any age, but benefits are more likely to outweigh risks for symptomatic women before the age of 60 years or within 10 years after menopause. There are nonhormonal therapies available for hot flashes.
- Hormone therapy is effective for the prevention of osteoporosis-related fractures in women at risk for bone loss before age 60 years or within 10 years after menopause.
- Estrogen-alone appears to reduce coronary heart disease events and all-cause mortality in women younger than 60 years of age and within 10 years of menopause. Data on estrogen plus progestogen show a similar trend for mortality, but a null (no significant increased risk) effect on coronary heart disease.
- Low-dose vaginal estrogen therapy is recommended for symptomatic women whose symptoms are limited to vaginal dryness or associated discomfort with intercourse.
- Estrogen can be used alone in women without a uterus, but progestogen or the new SERM bazedoxefine is needed to protect the uterus against cancer in women with a uterus.
- Hormone therapy may improve mood in early postmenopausal women with depressive and/or anxiety symptoms and possibly also in perimenopausal women with major depression. Antidepressant therapy remains first-line appropriate treatment for major depression.
- Deciding about hormone therapy requires an individual discussion which includes quality of life and health priorities of the woman as well as personal risk factors such as age, time since menopause and the risk of blood clots, stroke, ischemic heart disease and breast cancer.
- The risk of venous thromboembolism and ischemic stroke are increased with oral hormone therapy with a rare absolute risk below age 60 years. Observational studies point to a lower risk with transdermal therapy but no randomized trials have been done.
- The risk of breast cancer in women associated with hormone therapy is complex. The risk may be increased with the addition of a progestin if needed to estrogen therapy or related to the duration of use.
- The dose and duration of hormone therapy should be made on an individual basis, re-evaluated periodically and consistent with treatment goals and safety concerns.
- In healthy women with early menopause, systemic hormone therapy is recommended until at least the average age of the natural menopause (age 51).
- The use of custom-compounded bioidentical hormone therapy is not recommended as there are many bioidentical hormones available which are FDA approved, regulated, and monitored.
- The use of systemic hormone therapy is not generally recommended in breast cancer survivors, although low-dose vaginal estrogen can be considered with consultation with oncology.
The official 2016 Clinical Guidelines and Position Statement for NAMS should be published in December.
Please share this blog with your friends, co-workers, and loved ones who are sleepless, hot flashing, grumpy, moody, experiencing painful sex and are confused about their options or pretending these are not menopausal symptoms. (You know who they are!)
Stay tuned for more menopause society news!
My motto: Suffering in silence is OUT! Reaching out is IN!