Hormone therapy should be the first treatment option considered for menopause symptoms, according to a recent review which found that the risks may have been overstated.
The team of Canadian MDs found that hormone therapy can reduce vasomotor symptoms in up to 90% of patients with moderate-to-severe hot flushes, reduce bone fragility, improve sleep quality and mood disturbances, and potentially reduce the risk of diabetes.
The review, published 15 May 2023 in the Canadian Medical Association Journal, recommends menopausal hormone therapy, historically known as hormone replacement therapy (HRT), as first-line treatment in people without risk factors.
While previous research has shown hormone therapy can increase the risk of breast cancer and stroke, the researchers say the breast cancer risk was much lower in women aged 50-59 years, while the risk of stroke was lower for those under 60.
The median age of menopause was 51 years and symptoms could occur up to 10 years before a woman’s last menstrual period and last more than 10 years, with common symptoms that affected overall health, quality of life and work productivity.
Corresponding author, Dr Iliana Lega, from the Toronto Women’s College Hospital and University of Toronto, explained that their review examined the latest evidence for diagnosing and treating menopausal symptoms as well as the risks and benefits of therapies to help clinicians and patients manage the condition.
“Menopausal hormone therapy is the first-line treatment for vasomotor symptoms in the absence of contraindications,” Dr Lega said.
“Although many treatments exist for menopausal symptoms, fears around the risks of menopausal hormone therapy and lack of knowledge regarding treatment options often impede patients from receiving treatment.
“Despite early concerns of an increased risk of cardiovascular events with menopausal hormone therapy after the Women’s Health Initiative trial, increasing evidence shows a possible reduction in coronary artery disease with menopausal hormone therapy among younger menopausal patients, specifically those who start menopausal hormone therapy before age 60 years or within 10 years of menopause.”
The estrogen component of menopausal hormone therapy reduced menopausal symptoms, progesterone protected the endometrium from hyperplasia and reduced the risk of endometrial cancer, and treatment with a combined regimen (or estrogen alone, in patients who have had a hysterectomy) reduced the frequency and severity of hot flashes and night sweats by around 75%.
“There are also metabolic benefits to menopausal hormone therapy which include an improvement in lipid profile: an increase in high-density lipoprotein, a decrease in low-density lipoprotein, and a decrease in lipoprotein,” the researchers said.
“Some studies also suggest an improvement in insulin sensitivity and, perhaps, a reduction in risk of diabetes, though for both lipid and insulin sensitivity, the benefits are seen primarily with oral estrogen therapy (which may also increase triglyceride levels) rather than transdermal formulations, given their hepatic first-pass effects.”
The team said that GPs should consider the individual risk factors of each patient when considering if hormone therapy was appropriate, and that for the average-aged menopausal or perimenopausal patient, with no contraindications or specific individual risk factors, no specific hormone regimen was preferred.
“Although many RCTs and observational studies have shown an increased risk of breast cancer with menopausal hormone therapy, these findings need to be interpreted carefully in the context of the individual patient,” the authors said.
“The WHO first reported that patients treated with combined menopausal hormone therapy had an increased risk of invasive breast cancer with a hazard ratio of 1:2.
“However, the attributable risk is much lower among people aged 50–59 years or among those who start treatment within the first 10 years of menopause, for whom the additional risk of breast cancer is estimated at three additional cases for every 1,000 women who use combined menopausal hormone therapy for 5 years.”
They also noted that for people with risk factors or those who did not want to take menopausal hormone therapy, nonhormonal therapies – such as some selective serotonin reuptake inhibitors (SSRIs) and other medications – could help alleviate symptoms.
Complex patients should be referred to specialists.