Hormone therapy at menopause re-visited

The North American Menopause Society (www.menopause.org) has just released an updated position statement on the use of hormone therapy (estrogen +/- progestin) at menopause for the treatment of menopausal symptoms. This well written document is the result of an extensive review of the literature before and after the initial presentation of the results of the Women’s Health Initiative.

Up front it remains clear that hormone replacement is the most effective therapy with which to treat symptoms of the menopause and, as is the case with all other therapies for all conditions, the lowest effective dose for that patient is the most appropriate.

The initial announcement of the estrogen plus progestin arm of the clinical trial was widely publicized and debated around the world and dramatically changed both physician and patient behavior. The estrogen only arm created much less consternation and received much less public attention. (My recollection, which may be faulty, was that it was made public on or near Super Tuesday 2004 — not a date to get much media coverage.)

Subsequent analysis and sub-analysis of the estrogen plus progestin and estrogen only clinical trials have refocused some of the current thinking. The WHI was not a study of the menopause transition but a study of post-menopause with the average age of the subjects — 63 years and most more than five to 10 years post menopause. Analyses based on years post menopause rather than age suggested that some adverse events (e.g. cardiovascular disease) were in fact protected by hormone therapy when begun early in the menopause, while others (e.g. thrombo-embolic events) were not so related.

Breast cancer risk is clearly the major concern to most of our patients and to us. That breast cancer is most often an estrogen dependent disease is not in dispute. There is also now dispute that most breast cancers in postmenopausal women occur in those who have never taken post menopausal estrogen. How to decide in the individual patient is the question. If the menopausal symptoms are intolerable then use of estrogen seems very appropriate. If risk factors for breast cancer are evident, such as a positive family history, the threshold for considering hormone replacement increases substantially.

How should we quantitate the benefits and risks? I encourage you to get a copy of the new NAMS document, read it carefully and then develop your own algorithms for use in your practice. This is no longer an easy decision for us to make but it no less important.