Guidelines for postmenopausal hormone therapy

I remember when the results of the Women’s Health Initiative were released several years ago.

Women on hormone therapy called asking what to do. Many who had been doing well without problems or risk factors were told by their physicians that they must cease therapy immediately; no further refills would be prescribed. Some women were forced to discontinue, even despite not being in the population studied, including young women post surgical menopause. Others were not certain who to believe amidst the controversy. They either continued or stopped depending on their level of concern.

In the months that followed, many asked to if I could reinitiate HT. Symptoms of estrogen deficiency returned and they felt poorly. For those without risk factors, I replied, “Of course. I probably would not have stopped HT in the first place. I certainly would not have stopped without discussing with you.”

Without going too much into the detail of the WHI study, the estrogen-progestin arm was stopped early because there was an increased risk for myocardial infarction, stroke, breast cancer and thromboembolic events. This risk was thought to outweigh the benefits of decreased fracture and colorectal cancer. The increased risk for breast cancer and venous thromboembolic events were not a surprise. However, the increased risk for cardiovascular events and stroke was.

The relative increase in MI was 19%; however the absolute difference in MI was seven more events per 10,000 in the treatment arm when compared with placebo — an absolute increase of only 0.07%.

Since then, other studies have called into question some of the concerns that were raised by WHI. Some studies suggest there may be a difference depending on the type of HT used. Others have suggested that there may be a trend towards decreased MI and other CV events in younger women initiated early compared with older women or in those with risk factors.

The North American Menopause Society recently released an updated position statement for HT in postmenopausal women. In summary, they believe the benefit-risk ratio for menopausal HT is favorable for women who initiate HT close to menopause, but decreases in older women and with time since menopause in previously untreated women. This is a step forward from the more general recommendations that have been made in the past.

The title of the last section says it best: “Individualization of therapy is key.” Everyone is unique. There is no single best approach. HT is beneficial for treatment of symptoms of menopause and may reduce risk for osteoporosis and fracture. However, benefits decrease with age and time after menopause. Older women and women with risk factors such as personal or family history of breast cancer, those with pre-existing or at high risk for CV, cerebrovascular, venous thromboembolic events may not be ideal candidates for HT.

All women should have thorough evaluation and discussion of the risks and benefits of HT before therapy is initiated, stopped or withheld.