Accordingly, NAMS has modified its guidance. To step back for a moment, in the abstract of its 2010 Position Statement, NAMS had concluded that:
- 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 benefit-risk ratio for menopausal HT is favorable for women who initiate HT close to menopause but decreases in older women and with time since menopause in previously untreated women.
Contrast that with the conclusion in the abstract of the Society’s 2012 Position Statement:
- Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms and to prevent osteoporosis in women at high risk of fracture. The more favorable benefit-risk ratio for ET allows more flexibility in extending duration of use compared to EPT where the earlier appearance of increased breast cancer risk precludes a recommendation for use beyond 3 to 5 years.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
When counseling menopausal women who are considering starting or continuing HT, I point out that HT represents the most effective treatment for bothersome menopausal symptoms and is highly effective for preventing osteoporotic fractures and genital atrophy.
Almost all of my patients who are considering starting systemic HT are in their late 40s or in their 50s—within a decade of the onset of menopause. If these women have had a hysterectomy, I counsel them that estrogen-only HT is likely to reduce their risk of coronary artery disease (CAD). On the other hand, if these women have an intact uterus, I counsel them that combination estrogen–progestin HT does not increase their risk of CAD—and might prevent it.
I also point out that starting HT and continuing it over the long term may reduce their risk of dementia later in life.
I do prescribe oral and transdermal estrogen, but I more often prescribe transdermal formulations because of their apparent safety in regard to the risk of venous thromboembolism. This preference for transdermal estrogen applies, in particular, to overweight women because their baseline risk of VTE is elevated.
Regarding breast cancer, I point out to estrogen-only HT candidates that HT prevents breast cancer. I counsel women whose uterus is intact that women who use combination HT for longer than 3 to 5 years experience a modest increase in their risk of having a diagnosis of breast cancer—similar to the elevation associated with moderate alcohol consumption. I also point out that the risk of dying from breast cancer might be increased with long-term combination HT use.
In women for whom the only indication for HT is prevention of genital atrophy, I prefer to prescribe vaginal formulations of estrogen.
Some of my patients—particularly those who do not have a uterus—who are extensively counseled, choose to continue HT indefinitely. Such very-long-term users often focus on either 1) their greater sense of well-being with HT or 2) the benefit of the prevention of osteoporosis in the face of their desire to avoid long-term bisphosphonate therapy.
Last, over the course of patients’ years of taking HT, I encourage them to try lower dosages, until they either discontinue HT or remain on a very low dosage.
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