New hormone replacement therapy (HRT) statement from NAMS.

September 1, 2008

The North American Menopause Society recently updated its position on hormone therapy.

Hormone therapy (HT) for postmenopausal women is evolving rapidly. To guide health-care providers and the lay public concerning the risks and benefits of HT after menopause, The North American Menopause Society has updated and expanded its March 2007 position statement.

The new position statement, incorporating the most recent evidence about HT for menopause-related symptoms, includes new discussions of vaginal symptoms, sexual function, urinary health, body weight, endometrial cancer, depression, total mortality, dosages, routes of administration, regimens, timing of initiation of therapy, duration of use, discontinuance, and individualization of therapy. It also expands on previous discussions of cardiovascular effects, breast cancer, cognition, and bioidentical hormones. An addendum provides details on how to explain HT risks to patients. The full text of the document can be viewed on the NAMS Web site at http:// http://www.menopause.org/PSHT08.pdf.

Vaginal symptoms

Sexual function

Treating moderate-to-severe vaginal atrophy with systemic ET or combination estrogen-progestogen therapy (EPT) or local ET can relieve dyspareunia. HT alone should not be used to treat other problems of sexual function, including diminished libido.

Urinary health

Some women with vaginal atrophy who have urge incontinence may benefit from local ET. However, it's not clear whether overactive bladder responds to ET by any route. Similarly the benefits of local ET for pure stress incontinence are controversial; and systemic HT may actually exacerbate or trigger stress incontinence. Local ET may lower the risk of recurrent urinary tract infection. Keep in mind though that no HT product is approved in the United States for any urinary conditions.

Cardiovascular effects

HT may reduce the risk of coronary heart disease (CHD) when started in early postmenopause. While longer duration of therapy is associated with lower CHD risk and mortality, short-term HT may increase the risk of CHD risk in women who are farther beyond menopause at the start of therapy. And HT is not recommended for the sole or primary indication of protecting women of any age against CHD.

Both ET and EPT apparently increase the risk of ischemic stroke (although evidence is mixed), but do not affect the risk of hemorrhagic stroke in postmenopausal women. HT is not recommended for primary or secondary stroke prevention.

Data suggest that oral HT increases the risk of venous thromboembolism (VTE) in postmenopausal women. The risk, which falls into the rare category statistically, appears within the first year or two of therapy and decreases over time. Risk of VTE is lower in women younger than 60 years who are taking either ET or EPT, as seen in the Women's Health Initiative (WHI). Limited observational data suggest that the risk of VTE may be lower with transdermal than oral ET. Lower HT doses may be safer than higher doses, but no randomized controlled trials (RCTs) exist to confirm this.

Endometrial cancer

Unopposed systemic ET increases the risk of endometrial cancer in postmenopausal women with an intact uterus; the risk is related to dose and duration of therapy (an increase as great as fivefold at the standard dose for more than 3 years). Concomitant progestogen is recommended to counteract the risk. Limited evidence exists to support HT in women with stage I or II endometrial cancer.

Breast cancer

The risk of breast cancer increases with EPT longer than 3 to 5 years; increased absolute risk was rare in the WHI trials. The effect on risk of continuous versus sequential progestogen remains unclear.

In the WHI trial of ET, the risk of breast cancer did not increase after more than 7 years of use. Available evidence suggests that using ET for fewer than 5 years has little effect on risk.

The question of whether to use HT in women with a history of breast cancer remains unresolved because of mixed, limited epidemiologic data and a lack of long-term RCTs.

Mood and depression

The evidence concerning the effect of HT on mood in postmenopausal women without clinical depression is mixed. Evidence is insufficient to support using HT to treat depression.