North American Menopause Society Releases New Position Statement on Hormone Therapy in Postmenopausal Women

The use of estrogen in the treatment of women has radically changed over the past fifteen years. Fifteen years ago virtually all women were encouraged to take estrogen soon after menopause in order to prevent cardiac disease. At this point in time we knew that there may be an elevated risk to develop breast cancer with estrogen therapy, but we counseled our patients that estrogen helped to prevent the leading killer of women, cardiac disease. Then in 2002, the Women’s Health Initiative (WHI) Study changed the landscape of hormone therapy for women.
This very large scale study determined that the risks of hormone therapy outweighed any perceived benefits, and women throughout the country were told to stop taking their estrogen. Unfortunately, this study was flawed from the beginning and did not yield results that were generally applicable to the recently menopausal woman who was considering hormone therapy to control symptoms of this life transition. We have now realized the problems with the WHI study and have swung back to a more reasonable, individualized approach to hormone therapy in women, and have also realized that estrogen therapy may indeed prevent cardiac disease when initiated soon after menopause. Our larger questions which now need to be addressed include the safety and efficacy profiles of various preparations. While prolonged estrogen and progestin use may increase a woman’s risk to develop breast cancer or thromboembolic disease (problems from blood clots) the benefits for some women may outweigh this risk.
The North American Menopause Society (NAMS) has released today an updated position statement on the use of estrogen and progestogen in postmenopausal women. NAMS is a non-profit organization which has previously released position statements from advisory panels consisting of clinicians and researchers who are experts in the field of women’s health. This is an updated version from their 2008 release. Their goal is to clarify the risk benefit ratio of hormone therapy with estrogen and progestin in the treatment of menopause symptoms and disease prevention. They have concluded that the use of hormone therapy should be consistent with treatment goals, benefits and risk for the individual woman. They note that the benefit and risk ratio will change for each woman with her age and her menopausal symptoms as she ages.

The below summarizes and highlights their recent position statement.

Benefits of the use of hormone therapy include:

Relief of vasomotor symptoms (hot flashes and night sweats)Treatment of vaginal atrophy (dryness).

Improvement of sexual function through relief of dryness and increase sexual satisfaction due to increased blood flow and sensation in the genital tissues.

Improvement in urge incontinence (a form of urinary incontinence).

Decreased risk of recurrent urinary tract infections.

Prevention of osteoporosis.

Early initiation of hormone replacement therapy does not increase cardiac disease and may reduce cardiac disease.

May lead to improved mood (data is mixed).

Risks:

Elevated risk of uterine cancer when estrogen is used without a progestin (five times elevated risk after three years of estrogen alone use).

Breast cancer is elevated in women treated with combined estrogen and progestin therapy after 3-5 years of use; however women treated with estrogen alone having a lower risk of developing breast cancer but may increase after 10-15 years of use.

May increase dementia when hormone therapy is initiated in older women (over 65 years).

There is currently no data to determine if one type of estrogen or progestin has a better safety profile, however there are likely to be differences of different regimens Transdermal estrogens (patches and gels or mists) do not increase triglycerides, lead to no change in C reactive protein and have little effect on blood pressure. They may also be associated with a lower incidence of deep venous thrombosis.

Usage recommendations:

A progestin is generally not recommended to be used in conjunction with ultra low dose vaginal and transdermal estrogens; however the addition of progestins may improve vasomotor symptoms.

The lowest effective dose of estrogen consistent with treatment goals, benefits and risks for the individual woman should be the therapeutic goal, with the addition of a progestin added if the woman has her uterus in place.

There is emerging data that the timing of initiation of hormone therapy is important, and that early initiation of therapy may reduce total mortality and heart disease risk. Therapy should not be initiated in women over the age of 60 years without a compelling indication.

The length of use is not well established and extending the use of hormone therapy for an extended period of time if the symptom benefit outweighs the risk and for the woman who is on estrogen replacement therapy for her bones when other treatments are not appropriate.

Bioidentical hormone therapy:

The term “bioidentical hormone therapy” generally refers to estrogens and progestin naturally produced in women. However the term is many times used to describe custom made preparations that are compounded for an individual according to a healthcare provider’s prescription. These are generally made in compounding pharmacies. These compounds have not been tested for safety or efficacy by the FDA and they are not FDA approved. NAMS recommends that filled prescriptions for bioidentical hormone therapy should include a package insert identical to those that have regulatory approval. The FDA has stated that there is no scientific basis for using saliva testing to adjust hormone levels.

Summary:

Therapy should be individualized.

There is a growing body of evidence that each type of estrogen and progestin, route of administration, and timing of therapy has distinct beneficial and adverse effects.
Further research remains essential.

Posted: February 16th, 2010 | Author: | Filed under: estrogen, gynecology, menopause, science | Tags: , , , , | 1 Comment »