The North American Menopause Society (menopause.org) just published their updated 2017 position statement on the use of hormone replacement therapy. The new recommendation encourages providers to have a conversation with their menopausal patients that is individualized for a specific woman’s needs instead of the 2012 recommendation that when prescribing hormones use smallest dose for the shortest time possible. The 2017 statement reflects new literature and consensus recommendations about the unique risk/benefit ratio of hormone replacement for women younger than 60 or who are within 10 years of their menopause (where there are more benefits then harm) vs. women over 60 years old. The new mantra is to use an appropriate dose, duration, regimen and route of administration that is individualized with shared decision making when considering hormone therapy. Hormone therapy is currently FDA approved for four indications: bothersome hot flashes, prevention of bone loss, low estrogen state due to premature ovarian failure, and genitourinary symptoms.
Hot Flashes: Hormone therapy has been shown in double-blind randomized trials to relieve hot flashes and is approved as first line therapy for relief of menopause symptoms in appropriate candidates. Hot flashes persist on average 7.4 years and appear to be linked to cardiovascular, bone, and cognitive morbidity. Compared with placebo, estrogen alone or combined with a progestogen is the “gold standard” to reduce weekly symptom frequency by 75%. Estrogen alone can be used in women with a prior hysterectomy. Micronized progesterone 300 mg nightly, significantly decreases hot flashes and improves sleep.
Osteoporosis: Hormone therapy prevents bone loss in healthy postmenopausal women and significant reduction in hip fractures. For women with hot flashes aged younger than 60 years or who are within 10 years of their menopause onset, hormone therapy is the most appropriate bone protective therapy in the absence of contraindications.
Genitourinary Syndrome of Menopause (GSM): Low dose vaginal estrogen preparations (cream, ring, pills) are effective at reducing genital dryness, burning, irritation, painful intimacy, and urinary urgency, frequency, and recurrent UTI’s. These low dose preparations have minimal systemic absorption, and are preferred over systemic therapies. Progesterone is generally not indicated when estrogen therapy is administered vaginally at recommended low doses. Vaginal estrogen can decrease urinary incontinence and overactive bladder whereas oral estrogen can exacerbate incontinence. Non-estrogen prescription therapies that improve GSM in postmenopausal women are Ospemifene and intravaginal DHEA. Fractional CO2 laser therapy, MonaLisa Touch, is FDA approved for use in the vagina and has over 25 clinical published studies on safety and efficacy.
Sexual function: Systemic hormones and low-dose vaginal hormones provide effective treatment of GSM by increasing lubrication, blood flow and sensation in genitourinary tissues.
Sleep Disturbances: Hormone therapy in the form of low dose estrogen or progestogen can improve chronic insomnia in menopausal women.
Skin, Hair, and Special Senses: Estrogen appears to have beneficial effects on skin thickness and elasticity and collagen synthesis. Changes in women’s hair density worsen after menopause, but no positive role has been identified for hormone therapy.
Next month I will summarize the effects hormones have on mood, cancer risk, cardiovascular morbidity and all-cause mortality.
