What is the recommended treatment approach for menopause using Hormone Replacement Therapy (HRT)?

From the Guidelines

Hormone Replacement Therapy (HRT) for menopause should be used at the lowest effective dose for the shortest duration needed to manage symptoms, as recommended by the USPSTF 1. The goal of HRT is to alleviate menopausal symptoms, such as hot flashes and night sweats, while minimizing the risks associated with therapy.

Key Considerations

• The decision to initiate or continue HRT should be made on the basis of discussions between a woman and her clinician, taking into account the individual's medical history, risk factors, and personal preferences 1.
• Women should be informed about the potential risks of HRT, including venous thromboembolism, coronary heart disease, and stroke, which may increase within the first 1-2 years of therapy, as well as the potential increased risk of breast cancer with longer-term use 1.
• The quality of evidence on the benefits and harms of HRT varies for different hormone regimens, and most evidence comes from observational studies that did not differentiate among the effects of specific hormone preparations 1.

Treatment Options

• Estrogen therapy alone may be used for women without a uterus, while estrogen plus progestogen may be used for women with an intact uterus to prevent endometrial cancer.
• Common estrogen options include oral estradiol, transdermal estradiol patches, or estradiol gel, and progestogen options include oral micronized progesterone, medroxyprogesterone acetate, or levonorgestrel in combination products.
• Treatment typically begins with a low dose and is adjusted based on symptom response, with regular follow-up appointments to assess effectiveness, side effects, and determine when to attempt discontinuation, which should be done gradually by tapering the dose 1.

From the Research

Recommended Treatment Approach for Menopause using Hormone Replacement Therapy (HRT)

The recommended treatment approach for menopause using HRT involves several considerations, including:

• The primary indication for initiating HRT, such as treatment of vasomotor and urogenital symptoms associated with the menopausal transition 2
• The use of the lowest effective dose for the shortest time necessary 2
• Assessment of the patient's medical history, presence of contraindications to HRT, and personal risk of cardiovascular disease and breast cancer 3, 4
• Consideration of the type of HRT, dosing, and route of administration, as well as recommendations regarding duration of therapy 3, 5, 6

Patient-Specific Considerations

Patient-specific considerations that should be weighed when prescribing HRT include:

• Age and time since menopause, as these are strong predictors of health outcomes and absolute risks associated with HRT 6, 4
• Presence of contraindications to HRT, such as history of breast cancer or cardiovascular disease 4
• Patient preference regarding therapy, as well as their individual risk-benefit profile 4
• The need for regular review of the patient's need for continued treatment, and consideration of tapering or discontinuing HRT as needed 2, 5

Benefits and Risks of HRT

The benefits and risks of HRT should be carefully reviewed with the patient, with an emphasis on absolute rather than relative measures of effect 4. The benefits of HRT include:

• Effective treatment of vasomotor and genitourinary symptoms of menopause 3, 5, 6
• Positive effects on bone health and coronary heart disease in younger women 6 The risks of HRT include:
• Increased risk of stroke, cardiovascular disease, breast cancer, and venous thromboembolism 5, 6, 4
• Potential for troublesome symptoms associated with stopping HRT, such as vasomotor symptoms 2