NAMS updates position statement about Hormone Therapy at the 2017 annual meeting

courtesy: dailytimes.com

The North American Menopause Society(NAMS) executive director, JoAnn Pinkerton, MD, from the University of Virginia in Charlottesville, issued the updated Hormone Therapy(HT) Position statement at the ongoing annual meeting at Philadelphia October 11-14, 2017.

This update’s the 2012 statement from NAMS, and includes special needs population like women who had early menopause or breast cancer.

The recent findings from Women’s Health Initiative(WHI) follow-up study, published recently reinforced the development of this position statement. The results of follow-up study showed no increase in all-cause or disease specific mortality in women taking hormone therapy.

The advisory panel reviewed WHI data along with 13 years of follow -up, plus newer randomized trial and other observational data and studied the effect of HT on a wide range of diseases.

Recommendations:

NAMS urges the health practitioners to assess each individual woman based on her unique health risk and co-morbidities, and make a shared, informed decision about staring the HT. The women should be revaluated and her risk reassessed periodically.

The practitioners should choose the best dose, combination, route and duration of therapy for each individual patient.

HT is most effective in treating hot flashes, night sweats, and sleep disruption caused by menopause in addition to preventing bone loss and fractures.

Risk of HT differ according to the duration, timing of starting the therapy, type and route of administration and formulation. Risks vary according to the addition of progesterone.

Always use the lowest and safest dose that brings about relief of symptoms.

HT is safe for most menopausal women age less than 60 years or when started within 10 years of menopause.

The benefits of starting HT decreases and the risk increases (Increased benefit/risk ratio) if started 10-20 years after menopause or after the age of 60 years. In these women low dose vaginal estrogen is recommended for relief of Genitourinary syndrome(GSM).

Special populations:

Breast cancer: The WHI study data analysis did not show any increased risks with conjugated estrogen alone during the study period (7 years), but some studies have suggested increased risk after 15-20 years. The rare risk of <1/1000 for breast cancer appears to be due to combination of estrogen and progesterone or extended duration of estrogen alone.

CVD: HT reduces the risk of CHD when started at younger age or within 10 years of menopause and no effect of risk reduction was observed when it was initiated 10-20 years after menopause or after the age of 60 years.

Early menopause: Unless contraindicated, women who have had premature ovarian failure or surgically induced menopause should receive HT till median age of 52 years as benefits outweigh the risks. (Level II).

Family history of breast cancer: Evidence shows that HT does not alter the risk of breast cancer in women with FH of the disease, however she should undergo counselling about it. (Level II).

BRCA-positive women without breast cancer: These group of women are at high risk of primarily estrogen-receptor negative breast cancer. To mitigate the health risk caused by oophorectomy, systematic HT can be started after shared decision making until the median age of natural menopause. (Level II).

Extended use of HT: The recent data does not support the routine discontinuation of HT after the age of 65 years as per Beers criteria. Each woman should be individually assessed to continue HT beyond the age of 60 years. Her risk should be reassessed and close follow-up is needed. (Level III).