The Latest Data On Hormone Use After Menopause

     Dear Patient,

As part of my commitment to providing up-to-date information to you I am happy to present:

The North American Menopause Society
Position Statement On The Use of Hormone Therapy 
issued by a scientific advisory panel
February 27, 2007

(My editorial comments are in blue italicised type)

• Agreement was reached on the following issues:
• All women should receive a comprehensive assessment before HT (hormone therapy), including mammography and bone densitometry, according to clinical guidelines.
• The primary indication remains the treatment of vasomotor symptoms, and systemic estrogen and EPT (estrogen + progesterone therapy) are approved for this indication.
• When estrogen therapy is considered solely for vaginal dryness, topical (not systemic) therapy should be considered first-line therapy.
• Women without a uterus should not be prescribed a progestogen with estrogen, and progestogen is not generally indicated for low-dose estrogen therapy administered locally for vaginal atrophy.
• There is insufficient evidence regarding the off-label use of long-cycle progestogen (e.g., every 3 - 6 months for 12 - 14 days) and vaginal or intrauterine administration as an alternative to EPT.
• Estrogen/EPT use for primary prevention in relation to timing of menopause needs further evaluation, and disparities about CHD (coronary heart disease)  prevention exist in relation to the proximity of menopause.
• Data do not currently support EPT use for secondary CHD prevention.
• The data show a reduction in CHD in women 50 to 59 years old who initiate EPT within 10 years of menopause, and an increased risk in women who initiate after 10 years.
• The attributable risk for CHD remains very low in younger postmenopausal women.
• The risk for VTE (venous thromboembolism - blood clot) is highest within 1 to 2 years after initiation of systemic HT, and VTE risk is estimated at 11 additional cases for EPT and 2 additional cases per 10,000 per year for estrogen therapy in women 50 to 59 years old.
• Both estrogen and EPT increase stroke risk, with 8 additional strokes for EPT and 12 additional cases per 10,000 per year for estrogen therapy.
• Large randomized trials suggest a reduction of diabetes risk with HT, with a 21% to 35% relative risk reduction (RRR) for EPT (15 fewer cases per 10,000 per year) and a 12% RRR (14 fewer cases per 10,000 per year) for estrogen therapy.
• Breast cancer risk is slightly increased with EPT use beyond 5 years for 4 to 6 additional invasive cases per 10,000 per year.
• Estrogen and EPT reduce risk for osteoporotic fractures and should be considered an option for women at high risk for fractures within 5 to 10 years.
• Evidence is insufficient to support the use of estrogen/EPT for depression.
• Initiating EPT after age 65 years is not recommended for the primary prevention of dementia or cognitive decline because risk can be increased during the ensuing 5 years.
• Lower than standard doses of estrogen/EPT should be considered, such as 0.3 mg of oral conjugated estrogens or 0.25 to 0.5 µg of oral micronized ß-estradiol, but these have not been tested in long-term trials.
• The long-term risk-benefit ratio for non-oral administration has not been tested.
• Extended use of the lowest effective dose is acceptable, provided the benefits of relief outweigh the risks in those at high risk for osteoporotic fractures and for further prevention of bone loss when alternative therapies are not available.
• "Bioidentical" hormones should be used with caution in absence of regulatory oversight and batch-to-batch variation in quality and purity.
• The panel could not reach consensus on the following:
• Whether cessation of HT should be abrupt or tapered.
• Whether there is a difference in breast cancer risk for continuous vs. sequential progestogen.

I would be happy to discuss specific issues above with you.

Lawrence C. Cairns, MD