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The Experts Do Agree About Hormone Therapy

Ten years have passed since publication of the first results of the Women’s Health Initiative (WHI) hormone therapy trials. The debate that followed gave women and their providers the impression that the experts don’t agree on the topic of hormone therapy. The purpose of this joint statement is to demonstrate the experts do agree on the key points.

The North American Menopause Society, the American Society for Reproductive Medicine, and The Endocrine Society take the position that most healthy, recently menopausal women can use hormone therapy for relief of their symptoms of hot flashes and vaginal dryness if they so choose. These medical organizations also agree that women should know the facts about hormone therapy. Below are the major points of agreement among these societies.

Hormone therapy reduces menopausal symptoms

  • Hormone therapy is the most effective treatment for menopausal symptoms such as hot flashes and vaginal dryness. If women have only vaginal dryness or discomfort with intercourse, the preferred treatments are low doses of vaginal estrogen.
  • Hot flashes generally require a higher dose of estrogen therapy that will have an effect on the entire body. Women who still have a uterus need to take a progestogen (progesterone or a similar product) along with the estrogen to prevent cancer of the uterus. Five years or less is usually the recommended duration of use for this combined treatment, but the length of time can be individualized for each woman.
  • Women who have had their uterus removed can take estrogen alone. Because of the apparent greater safety of estrogen alone, there may be more flexibility in how long women can safely use estrogen therapy.

Hormone therapy risks

  • Both estrogen therapy and estrogen with progestogen therapy increase the risk of blood clots in the legs and lungs, similar to birth control pills, patches, and rings. Although the risks of blood clots and strokes increase with either type of hormone therapy, the risk is rare in the 50 to 59 age group.
  • An increased risk in breast cancer is seen with 5 or more years of continuous estrogen/progestogen therapy, possibly earlier. The risk decreases after hormone therapy is stopped. Use of estrogen alone for an average of 7 years in the Women’s Health Initiative trial did not increase the risk of breast cancer.

Additional information:

In large population studies, estrogen therapy applied to the skin (patches, gels, and sprays) and low-dose estrogen pills approved by the United States Food and Drug Administration (FDA) have been associated with lower risks of blood clots and strokes than standard doses of estrogen pills, but studies directly comparing oral and transdermal hormone therapy have not been done.

There are many options for hormone therapy (estradiol and progesterone) approved by the FDA that are biochemically identical to the body’s own hormones. We don’t have scientific proof that custom-compounded bioidentical hormone therapy is any safer or more effective than FDA-approved hormone therapies. Many medical organizations and societies agree in recommending against the use of custom-compounded hormone therapy for menopause management, particularly given concerns regarding content, purity, and safety labeling of compounded hormone therapy formulations.

There is a lack of safety data supporting the use of hormone therapy in women who have had breast cancer. Non-hormonal therapies should be the first approach in managing menopausal symptoms in breast cancer survivors.

The Bottom Line:

Hormone therapy is an acceptable option for the relatively young (up to age 59 or within 10 years of menopause) and healthy women who are bothered by moderate to severe menopausal symptoms. Individualization is key in the decision to use hormone therapy. Consideration should be given to the woman's quality of life priorities as well as her personal risk factors such as age, time since menopause, and her risk of blood clots, heart disease, stroke, and breast cancer.

Medical organizations devoted to the care of menopausal women agree that there is no question that hormone therapy has an important role in managing symptoms for healthy women during the menopause transition and in early menopause. Ongoing research will continue to provide more information as we move forward.

This solidarity statement was drafted jointly by The North American Menopause Society, the American Society for Reproductive Medicine, and The Endocrine Society.
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