gynecology and obstetrics
Menopause
Menopausal Hormone Therapy
, a progestogen, or both) is the most effective treatment for menopausal symptoms ( Hormone therapy references ). It is used to relieve vasomotor and other systemic menopausal symptoms, treat symptoms due to vulvovaginal atrophy, and, for some patients, prevent or treat osteoporosis. Menopausal hormone therapy improves quality of life for many women by relieving their symptoms but does not improve quality of life for and should not be routinely given to asymptomatic postmenopausal women. If hormone therapy is needed to control menopausal symptoms, clinicians should determine the most appropriate type, dose, route of administration, and duration, based on goals of treatment and individual health risks. Potential benefits and harms due to hormone therapy should be periodically reevaluated. For healthy women with bothersome menopausal symptoms who are < 60 years old or < 10 years past menopause onset, potential benefits of hormone therapy are most likely to exceed potential harms. For women at risk of bone loss or fracture, hormone therapy reduces bone loss and incidence of fractures and can be used in women who are not candidates for first-line medications for osteoporosis. Starting hormone therapy in women who are > 60 years old or > 10 to 20 years past menopause onset is not generally recommended ( Hormone therapy references ). In these women, potential harms of hormone therapy (eg, coronary artery disease, stroke, venous thromboembolism, dementia) are likely to exceed potential benefits. Unless the clinical recommendation is clear, shared decision-making is recommended because of the following: Potential benefits and harms of hormone therapy can be complicated. The net benefit and harm can be marginal. Health risks may change with age. Women who have a uterus(ie, have not had a hysterectomy) are usually givenestrogen, and this must be given in combination with a progestogen (progesteroneor synthetic progestin), because unopposedestrogenincreases risk of endometrial hyperplasia and cancer. For systemic estrogen therapy, oral, transdermal (patch, lotion, spray, or gel), or vaginal forms may be used. Treatment should start with the lowest dose; the dose is increased every 2 to 4 weeks as needed. Doses vary by preparation. Examples of preparations and low doses for systemic therapy include 0.3 mg conjugatedestrogenorally once daily 0.5 mgestradiolorally once daily 0.014 to 0.375 mg a dayestradiolas a patch applied to the skin once or twice weekly 0.05mg a dayestradiolvaginal ring inserted every 3 months There are also dailyestradiolskin gels and sprays available in varying doses. The progestogen is taken continuously (ie, daily) or sequentially (cyclically; 12 to 14 consecutive days of every 4 week). Examples of preparations and doses are Medroxyprogesteroneacetate: 2.5 mg for continuous use and 5 mg for sequential use Micronizedprogesterone(a natural rather than syntheticprogesterone): 100 mg for continuous use and 200 mg for sequential use 52 mg (releases 20 mcg a day for 5 years, 10 mcg a day from 5 to 8 years) Intrauterine Device (IUDs; IUD) None Bleeding due to progestogen withdrawal is less likely with continuous therapy, although irregular bleeding can occur during the first 6 to 9 months of therapy. Combination products ofestrogenand a progestogen are available as pills and transdermal patches. Pills (eg, 0.3 mg conjugatedestrogensplusmedroxyprogesteroneacetate 1.5 mg once daily;norethindroneacetate 0.1 mg plusestradiol0.5 mg once daily) Patches (eg,estradiol0.045 mg pluslevonorgestrel0.015 mg a day released by a patch applied to the skin once weekly) For women who have had a hysterectomy,systemic estrogen therapy is used alone. receptor modulator [ Genitourinary syndrome of menopause treatment ]). This is a good option for women with a history of breast tenderness or bleeding on estrogen therapy and those with a family history of breast cancer. Bazedoxifene acts as an in peanut oil is contraindicated in women who are allergic to peanuts. Newer combination products do not contain peanut oil. The effect on bone density of progestogen-alone menopausal hormone therapy is uncertain. Bone density is decreased with use of certain progestogen contraceptives ( Progestin Contraceptive Injections ), and there is no effect with others ( When the only symptoms are urogenital,vaginal hormone therapy is preferred. Topical forms (eg, creams; vaginal tablets, suppositories, or rings) may be more effective for urogenital symptoms than oral forms and are sometimes used in addition to systemic therapy if these symptoms are not adequately treated. Vaginalestradioltablets, suppositories, rings, or creams in low doses (eg, 4 or 10 mcg for tablets, 7.5 mcg rings, 0.5 mgestradiolcream) deliver lessestrogento the systemic circulation. When vaginalestrogenis used at the lowest recommended doses, a progestogen is not needed. However, higher doses of vaginalestrogencan deliver as muchestrogenas oral or transdermal therapy and, if given to women who still have a uterus, require the addition of a progestogen. Any vaginal bleeding in women taking hormone therapy, whether systemic or vaginal, should be immediately evaluated to rule out endometrial cancer. Dehydroepiandrosterone (DHEA) may relieve vaginal dryness and other symptoms of vaginal atrophy; it is available and effective for relief of dyspareunia due to menopause ( is used, a progestogen is not needed; however, there are no long-term endometrial safety data for these medications ( Hormone therapy references ). ( Hormone therapy references ). In women who have recently been taking hormone therapy, hot flushes may temporarily increase, but in most women, hot flushes resolve after about 6 weeks. is contraindicated, nonhormone over-the-counter treatments (eg, vaginal lubricants, moisturizers) may be sufficient ( Hormone therapy references ). For moderate to severe genitourinary symptoms, treatments include Intravaginal estrogen Intravaginal DHEA Systemic hormone therapy Ospemifene may be used after consultation with their oncologist ( Hormone therapy references ). therapy has beneficial effects on bone density and reduces the incidence of fractures in postmenopausal women (not particularly those with osteoporosis). In one large study, hormone therapy reduced the incidence of fractures by 24% ( Hormone therapy references ). Nonetheless, Women are at significant risk of osteoporosis. They choose not to take Treatment . They are < 60 years old or < 10 years past menopause onset. Riskswith systemicestrogentherapy or combinedestrogen/progestogen therapy include Breast Cancer None Venous thromboembolism Overview of Coronary Artery Disease None Overview of Stroke None Endometrial Cancer , mainly if women who have a uterus take Overview of Biliary Function None Dementia None Types None Estrogentherapy may be contraindicated in women who have had or are at high risk of breast cancer, stroke, coronary artery disease, or thrombosis. The risk ofendometrial canceris higher in women who have a uterus and are given unopposedestrogentherapy. Nevertheless, any vaginal bleeding in a woman on any type of hormone therapy should immediately be evaluated to rule out endometrial cancer. acetate at 2.5 mg once/day) is used ( Hormone therapy references ). In the Women's Health Initiative randomized trial that compared oral when they are given oral standard dose combination therapy ( Hormone therapy references , acetate more adverse than for estrogens alone ( Hormone therapy references ). But for those aged 50 to 55 years at randomization, neutral results were seen at an average of 7.2 years post-intervention. therapy decreases incidence of recurrent urinary tract infections and improves stress and urgency incontinence ( Hormone therapy references ). Risk of all these disorders is very low in healthy women who take hormone therapy for a short time after menopause. Progestogens may have adverse effects (eg, abdominal bloating, breast tenderness, increased breast density, headache, increased LDL); micronizedprogesteroneappears to have fewer adverse effects, but may cause drowsiness (which can be minimized by taking at bedtime). Progestogens may increase the risk of thrombosis. There are no long-term safety data for progestogens. Before prescribing hormone therapy and periodically as therapy continues, clinicians should discuss its risks and benefits with women. 1.The 2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel: The 2022 hormone therapy position statement of The North American Menopause Society.Menopause9(7):767-794, 2022. doi:10.1097/GME.0000000000002028 2.Pinkerton JV, Pickar JH, Racketa J, et al: Bazedoxifene/conjugated estrogensfor menopausal symptom treatment and osteoporosis prevention.Climacteric15 (5):411–418, 2012. doi: 10.3109/13697137.2012.696289 3.Labrie F, Archer DF, Koltun W, et al: Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause.Menopause23 (3):243–256, 2016. doi: 10.1097/GME.0000000000000571 4.Constantine G, Graham S, Portman DJ, et al: Female sexual function improved withospemifenein postmenopausal women with vulvar and vaginal atrophy: Results of a randomized, placebo-controlled trial.Climacteric18 (2): 226–232, 2015. doi:10.3109/13697137.2014.954996 5.Faubion SS, Larkin LC, Stuenkel CA, et al: Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations from The North American Menopause Society and The International Society for the Study of Women's Sexual Health.Menopause2 5(6):596–608, 2018. doi: 10.1097/GME.0000000000001121 6.Rossouw JE, Anderson GL, Prentice RL, et al: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial.JAMA288 (3):321–333, 2002. doi:10.1001/jama.288.3.321 7.Chlebowski RT, Hendrix SL, Langer RD, et al: Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women's Health Initiative Randomized Trial.JAMA289(24):3243-3253, 2003. doi:10.1001/jama.289.24.3243 8.Chlebowski RT, Rohan TE, Manson JE, et al: Breast cancer after use of estrogen plus progestin and estrogen alone: analyses of data from 2 Women's Health Initiative randomized clinical trials.JAMA Oncol1(3):296-305, 2015. doi:10.1001/jamaoncol.2015.0494 9.Manson JE, Chlebowski RT, Stefanick ML, et al: Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials.JAMA310(13):1353-1368, 2013. doi:10.1001/jama.2013.278040 10.Cho L, Kaunitz AM, Faubion SS, et al: Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long?.Circulation147(7):597-610, 2023. doi:10.1161/CIRCULATIONAHA.122.061559 11.Christmas MM, Iyer S, Daisy C, et al: Menopause hormone therapy and urinary symptoms: a systematic review [published online ahead of print, 2023 May 16].Menopause10.1097/GME.0000000000002187, 2023. doi:10.1097/GME.0000000000002187 