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| 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).
