Updated position statement confirms menopausal HT benefits outweigh risks for most women
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Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms and genitourinary syndrome of menopause, according to an updated position statement from the North American Menopause Society.
In an article published in Menopause, the North American Menopause Society (NAMS) 2022 Hormone Therapy Position Statement Advisory Panel reaffirmed its support of menopausal HT for the treatment of vasomotor symptoms, saying the benefits outweigh the risks for most healthy women younger than 60 years andwithin 10 years of menopause onset. The position statement also emphasized personalized treatment, with a periodic reevaluation to analyze each individual’s benefit-risk profile.
“Since our last position statement on HT published in 2017, there have been important additions that further clarify the balance of risks and benefits of hormone therapy options for menopause symptoms,” Stephanie S. Faubion, MD, MBA, medical director of NAMS and director of the Mayo Clinic Center for Women’s Health, said in a press release. “NAMS has reviewed existing data on HT published after the last position statement, and after exhaustive research and review of the literature, we have found that what hasn’t changed is that HT remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture."
Menopausal HT effective, safe for most women
The document states that menopausal HT has been approved by the FDA for four indications: moderate to severe vasomotor symptoms; prevention of osteoporosis; treatment of hypoestrogenism caused by hypogonadism, bilateral oophorectomy or primary ovarian insufficiency; and treatment of moderate to severe vulvovaginal symptoms. Multiple randomized controlled trials have shown HT to be beneficial in treating each of these conditions.
The authors emphasize HT is safe to use for most healthy women younger than 60 years. After a review of observational data and reanalysis of older studies by age and time since menopause, the benefits of HT outweigh the risks for women within 10 years of menopause onset who experience bothersome menopause symptoms. Younger women have fewer cardiovascular disease events compared with older women, and women initiating HT within 10 years of menopause onset had a lower risk for coronary heart disease and all-cause mortality compared with placebo, according to the statement.
For women older than 65 years, there is no general evidence for halting HT, according to the statement. The researchers wrote that older women with persistent vasomotor symptoms can continue HT with appropriate counseling, a regular assessment of risks and benefits and shared decision-making.
Risk stratification is a crucial part of prescribing HT. The authors noted the risk for HT differs for each individual and can vary depending on the formulation, dose, duration of use, route of administration, timing of initiation and whether progestogen is needed. Transdermal routes of administration and lower HT doses may decrease risks for venous thromboembolism and stroke.
Menopausal HT and breast cancer risk
The authors wrote that some observational studies have found a possible rare risk for breast cancer with longer duration of HT use. The risk for breast cancer does not increase with short-term use of estrogen-progestogen therapy, however, and may be reduced with estrogen alone. For some survivors of breast and endometrial cancer, some observational studies have found the use of low-dose vaginal estrogen therapy is safe and can improve quality of life for those for whom non-hormone therapies fail to treat genitourinary syndrome of menopause.
The authors recommend against the use of compounded bioidentical HT, stating the formulations present many safety concerns, including overdosing or underdosing, the presence of impurities or lack of sterility, lack of evidence supporting efficacy and safety, and the lack of a label outlining risks.
Faubion said that while the position statement includes new research published since the last update in 2017, the overall message about HT’s benefit for most menopausal women and its recommendations for use have not changed from 5 years ago.
“It is extremely important to highlight the favorable benefit to risk profile of HT for management of vasomotor symptoms and genitourinary syndrome of menopause, particularly given that prescribing rates for both conditions continue to be low,” Faubion told Healio. “This suggests that there are many symptomatic women who would benefit from the use of HT and who are not receiving it. This translates to poorer quality of life and significant direct and indirect costs, including loss of work productivity, loss of income for women, increased health care utilization and health care costs.”
For more information:
Stephanie S. Faubion, MD, MBA, can be reached at faubion.stephanie@mayo.edu.
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