NAMS Notes: Position statement addresses hormone therapy in postmenopausal women

May 1, 2010

Data on hormone therapy (HT) for treating menopause-related symptoms and preventing disease in postmenopausal women are evolving rapidly. To guide therapy and to put the risks and benefits of HT, estrogen therapy (ET), or combined estrogen-progestogen therapy (EPT) in perspective for healthcare professionals and the public, the North American Menopause Society (NAMS) has updated its evidence-based 2008 statement in light of subsequently published scientific data.

Data on hormone therapy (HT) for treating menopause-related symptoms and preventing disease in postmenopausal women are evolving rapidly. To guide therapy and to put the risks and benefits of HT, estrogen therapy (ET), or combined estrogen-progestogen therapy (EPT) in perspective for healthcare professionals and the public, The North American Menopause Society (NAMS) has updated its evidence-based 2008 statement in light of subsequently published scientific data.

The 2010 position statement emphasizes recent data on breast cancer, cognitive aging/decline and dementia, coronary heart disease (CHD), stroke, and discontinuation of therapy. It includes new sections on ovarian and lung cancer. The full text is available on the NAMS Web site at http://www.menopause.org/PSHT10.pdf.

Assessing benefit and risk

Recent data support starting HT around the time of menopause. The benefit-risk ratio becomes less favorable with age and distance from menopause in previously untreated women. Hormone therapy is likely to be more acceptable for short-term treatment in younger women and less acceptable for long-term use and in older women. It may decrease total mortality when started soon after menopause but does not reduce mortality when started at 60 years of age or older.

Vasomotor and vaginal symptoms. Moderate to severe vasomotor symptoms, such as hot flashes and night sweats, remain the primary indication for HT. Estrogen therapy, with or without progestogen, is the most effective treatment.

It is also the best treatment for moderate to severe vulvar and vaginal atrophy. Less-frequent, lower doses of ET than were used previously often produce satisfactory results, although some ultra-low–dose systemic regimens may not relieve symptoms. Local vaginal ET is generally recommended for treating urogenital atrophy alone.

Systemic or local ET can relieve dispareunia. Hormone therapy alone is not recommended for other sexual function problems, including decreased libido.

Osteoporosis. Extended systemic HT to prevent postmenopausal osteoporosis is an option for women with decreased bone mass, women for whom other therapies are inappropriate, and women in whom the benefits of long-term therapy are likely to exceed the risks. Benefits decrease quickly after therapy ends.

Coronary heart disease. Hormone therapy is not recommended as a sole or primary indication for coronary protection at any age. Starting HT at 50 to 59 years of age or within 10 years of menopause does not appear to raise the risk of CHD; women who begin HT longer after menopause run a greater risk.

Emerging evidence suggests that starting ET alone soon after menopause may slow development of calcified atherosclerotic plaque and lower CHD risk.

Stroke. NAMS does not recommend HT for primary or secondary prevention of stroke.

Venous thromboembolism. Growing evidence suggests an increased risk of venous thromboembolism (VTE) with oral HT, especially in women with a history of VTE or factor V Leiden. Limited observational data point to a lower risk with transdermal ET than oral ET and lower doses rather than higher doses.

Diabetes mellitus. Evidence is inadequate to recommend HT as the sole or primary indication for preventing diabetes in perimenopausal or postmenopausal women.

Endometrial cancer. Women with an intact uterus taking systemic ET should take concomitant progestogen to counteract the risk of endometrial cancer. Hormone therapy is not recommended for women with a history of endometrial cancer.

Breast cancer. Diagnosis of breast cancer increases with EPT use longer than 3 to 5 years. Women who start EPT shortly after menopause may have a greater risk than women who start more than 5 years afterward. A modest trend points to declining risk over 3 years after EPT ends.

Data from the Women's Health Initiative (WHI) show no rise in breast cancer risk after an average of 7.1 years of ET use and significant risk reductions in 3 cancer subgroups: localized cancer, ductal carcinoma, and cancers at 6-month follow-up after discontinuation of ET. Observational data suggest that risk increases when women take ET longer than 10 to 15 years.

Ovarian cancer. Data on HT and ovarian cancer conflict. Most epidemiologic studies have found no association or a modest increase, whereas a relatively large volume of observational data point to increased risk. The association between ovarian cancer and HT beyond 5 years is rare or very rare; women at risk should be so counseled.

Lung cancer. Data on lung cancer and HT are confusing but reinforce the need to encourage women to avoid or stop smoking and perhaps to increase surveillance of older smokers who use or have used HT.

Cognitive aging and dementia. NAMS does not recommend HT at any age for the sole or primary indication of preventing cognitive aging or dementia or to enhance cognitive function in younger postmenopausal women with intact ovaries. Not enough data exist to indicate whether HT soon after menopause affects later dementia risk; HT appears to increase the incidence of dementia when started at age 65 years or older. Limited evidence does not support using HT to treat Alzheimer's disease.

Premature menopause. Do not extrapolate data on HT in women who experience menopause at the typical age of 51.3 years to those who experience premature menopause (before age 40). Most observational reports suggest that HT protects against CHD in women with early natural or surgical menopause. The risks of HT in these women may be smaller and the benefits greater than for older women.