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| courtesy: www.renewedvitalitymd.com |
The North
American Menopause Society has updated its position statement regarding menopausal and post-menopausal hormone therapy, replacing the earlier statement issued in 2012.
Instead of prescribing,
“lowest dose for the shortest period of time” which may be harmful for some
women, the new emphasis is on “appropriate dose, duration, regimen, and route
of administration that provides the most benefit with the minimal amount of
risk.”
The new
position statement was published online June 21 in NAMS’s Journal Menopause.
Hormone
Replacement Therapy remains the most effective treatment for vasomotor symptoms
(VMS) and Genitourinary symptoms of menopause (GSM) and helps prevent
osteoporosis and fractures.
The US FDA
approved indications for starting HRT are bothersome vasomotor symptoms and
genitourinary symptoms, Estrogen deficient states caused by premature ovarian
insufficiency (POI), hypogonadism and castration and prevention of bone loss.
Women who
are seeking relief for bothersome vasomotor symptoms are offered conjugated
equine estrogen (CEE) if they already had hysterectomy or it is paired with a
progestogen or with bazedoxifene, a selective estrogen-receptor modulator
(SERM), to protect users against endometrial cancer.
The statement
authors also suggest that micronized progesterone at a dose of 300 mg at
bedtime can be an effective treatment to reduce hot flashes and night sweats
and improves sleep.
Low dose,
intravaginal estrogen preparation is the treatment of choice for women with
vulvovaginal atrophy (VVA), because of minimum systemic absorption. For women who
are intolerant to estrogen, ospemifene or intravaginal DHEA is equally effective
in relieving the symptoms of atrophy. This preparation also bring relief from
urinary symptoms.
Systemic
Hormonal therapy is not effective in improving urinary incontinence and on the
other hand may exacerbate stress incontinence.
HRT in women
who have undergone surgical menopause or POI should be started early and at
least continued till the age of 52 years.
An important
update in this statement was about starting HRT in women with BRCA 1/2 mutation.
Dr. JoAnn V. Pinkerton, NAMS executive director said, "For BRCA-positive
women without breast cancer who have undergone risk-reducing bilateral
salpingoophorectomy, observational data suggest that systemic HRT to the median
age of menopause may decrease health risks associated with premature loss of
estrogen without increasing breast-cancer risk. "
Physician
should be cautious in starting HRT in women who are 10 years past menopause or
60 years old at the time of initiating HRT. In these group of women, the
benefit/risk ration is less favorable than for younger women because of
increased risk of stroke, CVD, venous thromboembolism and dementia.
If the women
are already on HRT, the therapy need not be discontinued abruptly at age 60 or
65 years. It may be continued past 65 years of age for persistent hot flashes,
prevention of osteoporosis, and quality-of-life issues, with an open dialogue
with the patients about the risk and benefits of HRT at this age.
Once HRT is
stopped, in 50% of women, vasomotor symptoms will recur, irrespective of age of
starting the therapy or duration of therapy quoted the authors of the statement.
And, nearly
all women, will lose [bone-mineral density], with increased risk of bone
fractures and excess mortality from hip fracture," they also point out.
Dr Pinkerton
added "And the risks of longer use of HRT may be minimized with the use of
lower doses of both estrogen and progestogens, the use of transdermal therapies
to avoid hepatic first-pass effect, or the combination of conjugated estrogen
paired with the SERM bazedoxifene, which provides endometrial protection without
the need for a progestogen."
NAMS has
also released a patient information sheet called ‘MenoNote’ that simplify the
facts and help women to decide using HRT. The ‘MenoNote’ is available on NAMS
website. It can be accessed here.
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