Hormone Therapy for Postmenopausal Women

Pinkerton JV.
Hormone Therapy for Postmenopausal Women. N Engl J Med 2020;382:446-455.

The following are key points to remember from this article about hormone therapy for postmenopausal women:

  1. Menopausal symptoms include vasomotor symptoms (hot flashes, night sweats) and a genitourinary syndrome (vaginal dryness, dyspareunia, urinary frequency, and infections). Undertreatment is associated with decreased quality of life.
  2. Hormone therapy can reduce hot flashes and night sweats, and reduce bone loss and fractures. Topical/local treatment improves genitourinary symptoms.
  3. Hormone therapy is most beneficial for women with symptomatic hot flashes or night sweats who are: 1) younger than 60 years old, or 2) within 10 years of the onset of menopause.
  4. Hormone therapy is not indicated for primary/secondary prevention of coronary heart disease.
  5. Post hoc analyses of the Women’s Health Initiative (WHI) trial support the “timing hypothesis,” which suggests low risk (and possibly some cardiovascular benefit) of hormone therapy when started close to the onset of menopause (within 10 years) and harm if started later (>10 years after onset of menopause or in women >age 60 years).
  6. Re-evaluation and tapering of hormone therapy at 3-5 years is recommended.
  7. Risk of thromboembolism and stroke may be lower with transdermal hormone therapy, based on observational studies.
  8. Consider using transdermal hormone therapy (rather than systemic) for women with: obesity or metabolic syndrome, diabetes, hypertriglyceridemia, high risk of thrombosis, low libido, migraines, and/or gallbladder/liver disease.
  9. Systemic hormone therapy is the most effective therapy for vasomotor symptoms. Consider nonhormonal therapy for women with the following:
    • Age ≥60 years or >10 years from menopause at initiation of therapy
    • Contraindications to hormone therapy
    • History of stroke, myocardial infarction, or pulmonary embolism
    • High risk of breast cancer, heart disease, or venous thromboembolism
    • Estrogen-sensitive cancer
    • Patient preference
  10. Nonhormone therapies, including low-dose selective serotonin-reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and gabapentinoids, can reduce hot flashes.
  11. Nonpharmacologic interventions have weaker evidence, but include weight loss, hypnosis, cognitive behavioral therapy, yoga, and acupuncture.
  12. If only genitourinary symptoms are present, local vaginal hormone therapy is recommended, rather than systemic treatment.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Hypertriglyceridemia

Keywords: Acupuncture Therapy, Breast Neoplasms, Coronary Disease, Diabetes Mellitus, Dyspareunia, Estrogens, Hormone Replacement Therapy, Hot Flashes, Hypertriglyceridemia, Libido, Liver Diseases, Menopause, Metabolic Syndrome, Migraine Disorders, Myocardial Infarction, Norepinephrine, Obesity, Postmenopause, Pulmonary Embolism, Quality of Life, Secondary Prevention, Serotonin Uptake Inhibitors, Thrombosis, Venous Thrombosis, Weight Loss, Women, Yoga

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