Guidance updated on use of hormone therapy
Add a new resource on menopause management to your clinical practice. The North American Menopause Society (NAMS) has just updated its guidelines on postmenopausal hormone therapy.1
The updated clinical recommendations, issued in the form of a position statement, represent the fifth issuance from the Cleveland-based nonprofit scientific organization. The goal of the new position statement is to clarify the benefit-risk ratio of hormone therapy (HT) — in its forms of estrogen therapy (ET) or combined estrogen-progestogen therapy (EPT) — for treatment of menopause-related symptoms and disease prevention during menopause and beyond. It does not include information on other modalities, such as selective estrogen-receptor modulators, phytoestrogens, and testosterone therapy.
The new position statement has received endorsement from several national and international organizations, including the American Medical Women's Association, the Endocrine Society, the National Association of Nurse Practitioners in Women's Health, the National Women's Health Resource Center, and the Society for Obstetricians and Gynecologists of Canada. NAMS, as well as these societies, are working to disseminate the information among all women's health providers, says Wulf Utian, MD, PhD, NAMS director.
In addition to publication of the statement in the NAMS journal, Menopause, and sister publication, Menopause Management, the statement is available online at the NAMS web site, www.menopause.org. A PowerPoint slide set that summarizes the statement also is available free of charge. (Editor's note: At the web site, click on "Other Healthcare Professionals," then "See the new NAMS Position Statement 'Estrogen and Progestogen Use in Post-menopausal Women,'" to download a copy of the statement, as well as the slide set.) The new statement includes information on vaginal symptoms, sexual function, urinary health, change in body weight and mass, endometrial cancer, and total mortality rates. Topics that have been expanded or modified include cardiovascular effects, breast cancer, mood and depression, cognitive aging and decline, dementia, and use of bioidentical hormones. The 2008 statement on hormone therapy considers the current best practice of medicine from a clinical perspective, Utian notes.
"The undue fear and confusion generated in recent years by overrepresentation or misinterpretation of clinical studies mandated a clearer explanation of the therapeutic benefit-risk ratio of HT after menopause, and how these benefits and risks affect both health providers and the women weighing the use of such therapy," he states.
The primary indication for hormone therapy remains directed at treatment of moderate to severe vasomotor symptoms, notes Utian. Estrogen therapy, with or without the use of a progestogen, is the most effective treatment of such menopausal symptoms as hot flashes and night sweats, according to the statement.
"Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both," the statement advises. "The benefit-risk ratio for menopausal HT is favorable close to menopause but decreases with aging and with time since menopause in previously untreated women."
Estrogen therapy also is the most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy, with local vaginal ET generally recommended when HT is considered solely for this indication. Although local ET also may benefit some women with urge incontinence who have vaginal atrophy, it still is unclear whether ET by any route of administration is effective in treating overactive bladder, the statement advises.
Extended use of HT is an option for women who have established reduction in bone mass, regardless of menopause symptoms, for prevention of further bone loss and/or reduction of osteoporotic fracture when alternate therapies are not appropriate or cause side effects, or when the benefit-risk ratio of the extended use of alternate therapies is unknown.
For women who are younger than age 50 or who are at low risk for coronary heart disease, stroke, osteoporosis, breast cancer, or colon cancer, the absolute risk or benefit from estrogen or estrogen/progestogen therapy is likely to be even smaller than that shown in the Women's Health Initiative; however, the relative risk may be similar at different ages, the statement observes.
One of the most challenging issues regarding HT is the duration of use, the guidance states. Existing data do not provide a clear indication as to whether longer duration of therapy improves or worsens the benefit-risk ratio, it concludes.1
An individual risk profile is essential for every woman contemplating any regimen of hormones for menopausal symptoms, advises the statement. An addendum to the statement reviews the basic issues of calculating risk, and defines such terms as absolute risk and relative risk, to help clinicians discuss such issues with women. Keep the following principles in mind when discussing risks:
- Instead of saying that there is a 20% chance of a side effect, say that two of every 10 women experience the side effect.
- Avoid presenting data with different denominators: "Headache developed in six of 500 women without the drug vs. 20 in 1,000 with the drug." Use the same denominator, such as 1,000 or 10,000: "Headache developed in 12 of every 1,000 women without the drug, compared to 20 of 1,000 women with the drug."
- Be aware of the hazard for the condition in the baseline population. Two times a very rare event still is a very rare event.1
"It is incredibly important that people understand what the levels of risk are that we talk about, or the level of benefits, when we actually use these numbers," says Utian.
Reference
- Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society. Menopause 2008; 15:584-602.
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