Hormone Therapy & Menopause
Menopause Hormone therapy (MHT) is one of the FDA-approved treatments for relief of symptoms related to menopause. These symptoms, caused by lower levels of estrogen before and after menopause, include hot flashes, sleep disturbances, and vaginal dryness. MHT is also approved for the prevention of osteoporosis (bone loss).
There are three stages of natural menopause:
Perimenopause is the time between the start of symptoms and 1 year after the final menstrual period.
Menopause is confirmed 12 months after the final menstrual period. It’s technically just… one day… of your life.
Postmenopause is all the months and years beyond your menopause day.
Basically, there are two types of MHT:
Estrogen-only therapy (ET). Estrogen is the hormone that provides the most menopausal symptom relief. ET is prescribed for women without a uterus due to a hysterectomy.
Estrogen plus progestogen therapy (EPT). Progestogen is added to ET to protect women with a uterus against uterine (endometrial) cancer from estrogen alone.
There are two ways to take MHT:
Systemic products. These products circulate throughout the bloodstream and to all parts of the body. They are available as an oral tablet, patch, gel, emulsion, spray, or injection and can be used for hot flashes and night sweats, vaginal symptoms, and osteoporosis.
Local (non-systemic) products. These products affect only a specific or localized area of the body. They are available as a cream, ring, or insertable tablet or softgel, and can be used for vaginal symptoms.
Current prescribing practice:
Healthcare practitioners will recommend an individualized plan for each woman. There is no “one size fits all” therapy. They will typically begin MHT with the lowest effective dose for the shortest amount of time consistent with the women’s individual goals. The benefit-risk ratio is favorable for women who initiate MHT close to menopause (ages 50-59, typically) but becomes riskier with time since menopause and advancing age. Women with early menopause before age 40 without a history of breast cancer risk can take MHT until the typical age of menopause at 51 if there is no reason not to take it.
Explaining the Benefits of MHT:
Hundreds of clinical studies have provided evidence that both systemic and local MHT (ET and EPT) effectively improves such conditions as hot flashes, night sweats, and fatigue. It can also treat genitourinary syndrome of menopause which could cause recurrent UTIs, painful sex, vaginal dryness. These benefits can lead to improved sleep, mood, sexual relations, and quality of life. One will also have a lower risk of bone loss which could lead to broken bones.
Explaining the Risks of MHT:
As a result of the Women’s Health Initiative (WHI) trial in 2002, the US FDA requires all estrogen-containing prescriptions to carry a “black box” warning in their prescribing information about the risks of MHT. Although only two products were studied in the WHI (Premarin and Prempro), the risks of all MHT products, including “natural” bioidentical and compounded hormones, should be assumed to be similar until evidence shows otherwise.
For women with a uterus who take EPT (estrogen plus progestogen therapy), there is no increased risk of uterine cancer. In fact, the combination therapy actually protects a woman against uterine cancer. The risk of breast cancer may increase very slightly if hormones are taken for more than 4 years, but at the time of diagnosis, breast cancer is likely to be a lower stage with a lower chance of death than women not on hormone therapy.
For women without a uterus who take estrogen, there is no increased risk of breast cancer for the first 7 years, but the risk may increase slightly if used for longer. For women with a family history of breast cancer, MHT does not further increase the risk of breast cancer.
Both ET and EPT have been associated with stroke and an increase in blood clots in the veins. These risks are higher in women over age 60.
Weighing Benefits & Risks:
There is no single way to ensure the best possible quality of life around menopause and beyond. Each woman is unique and must weigh her discomfort against her fear of treatment. Risk is defined as the possibility or chance of harm; it does not indicate that harm will occur. Generally, MHT risks are lower in younger women than originally reported in all women ages 50 to 70 combined. It is now believed that women taking estrogen alone—women who have had their uterus removed by a hysterectomy—have a more favorable benefit-risk profile than those taking EPT. This is especially true for younger menopausal women (in their 50s or within 10 years of menopause) than for older women.
Healthcare Practitioners have modified their views about the role of hormones as more research has been conducted. Experts agree that there is much they still have to learn. Although recent studies such as the WHI have provided some clarity for large populations, they don’t necessarily address all of the issues an individual woman faces. Only she, with the counsel of her healthcare practitioner, can do that.
Many factors will be part of a woman’s decision to use a particular hormone product—her age, her risks, her preferences, available treatment options, and the cost of the product. Do her potential benefits outweigh her potential risks? Only after examining and understanding her own situation and after a thorough consultation with her clinician can a woman make the best treatment choice. As new therapies and guidelines are available, and as a woman’s body changes over time, reevaluation and adjustments should be made.
For more information, visit The Menopause Society.
The 2022 Menopause Society’s Hormone Therapy Position Statement.
The 2023 Menopause Society’s Non-Hormone Therapy Position Statement.
