KEY POINTS
■ The North American Menopause Society estimates that 6,000 women daily and more than 2 million women each year enter menopause. Many of these women will experience symptoms during and after the menopausal transition that might be effectively treated with hormone therapy (HT).
■ HT fell out of favor when two landmark studies appeared to show that its risks outweighed its benefits. However, new studies suggest that for women aged 50 to 59 years—the group most likely to benefit from HT—the risks are not as prevalent as once believed.
■ HT is indicated for the treatment of moderate to severe vasomotor symptoms and vulvar/vaginal atrophy in symptomatic women and the prevention of postmenopausal osteoporosis.
■ HT should be initiated at the lowest available dosage. After 8 to 12 weeks of therapy, symptoms should be reassessed, and the dosage adjusted accordingly. Length of use should be re-evaluated annually. HT can be discontinued after 2 to 3 years but resumed if symptoms recur.
Clinicians are accustomed to treating patients who have medical illnesses; however, managing the symptoms associated with menopause—a natural, biologic process—is quite different. Hormone therapy (HT) using estrogen either with or without progesterone remains the most effective, and most studied, treatment.1 But many patients and clinicians have reservations about using HT because of the controversy surrounding it. All clinicians, regardless of their specialty, may encounter patients who have questions about the use of hormones. In family medicine practices, women may inquire about hot flashes and night sweats; in orthopedics practices, the treatment and prevention of osteoporosis; and, in gynecology practices, dyspareunia and vaginal atrophy. Clinicians should be able to respond with accurate, upto- date information on the recommendations for HT as well as its known risks and benefits.
The North American Menopause Society (NAMS) estimates that 6,000 women daily and more than 2 million women each year enter menopause.2 Menopause occurs in three stages: perimenopause, menopause, and post menopause. Perimenopause is when estrogen levels begin sporadically increasing and decreasing, leading to irregular menstruation and adverse symptoms, such as hot flashes. Perimenopause begins the transition to menopause and can last for 5 years or longer. Menopause is defined as the final cessation of menstrual periods and is confirmed after 12 consecutive months of amenorrhea. A woman is then considered to be postmenopausal. At this time, her ovaries produce very little estrogen and no progesterone, and ovulation has ceased. Typically, a woman experiences natural menopause between the ages of 45 and 54 years.
For clarification, this article uses the NAMS terminology: ET refers to unopposed estrogen therapy; EPT refers to combination estrogen and progestogen therapy; and the term progestogen refers to both progesterone and progestins. NAMS describes progesterone as being identical to the hormone produced by the ovaries, whereas progestins are synthesized compounds that act like progesterone. HT refers collectively to both ET and EPT.3
HISTORY OF HORMONE THERAPY
The first commercial hormone preparations became available in the 1920s.4 HT was initially prescribed for the prevention and/or treatment of chronic conditions. In the 1980s and 1990s, researchers believed that HT provided coronary benefits and potentially decreased the risks of osteoporosis, Alzheimer's disease, and overall morbidity. Its benefits were thought to outweigh the risks for women of all ages and at all stages during climacteric. Therefore, many clinicians and women were taken aback when the results of the Heart and Estrogen/progestin Replacement Study (HERS), published in 1998, showed that HT did not reduce the risks of coronary heart disease (CHD) events.5 In another surprise, the Women's Health Initiative (WHI) was stopped in 2002 because an increased incidence of CHD and breast cancer was seen among some study participants.6 In light of these study results, the risks of HT were then believed to outweigh the benefits for all women.