What are the best practices for Hormone Replacement Therapy (HRT) in menopause?

From the Guidelines

Hormone Replacement Therapy (HRT) in menopause should be individualized and used for the shortest duration possible, with careful consideration of the benefits and risks for each patient.

Best Practices for HRT

• Individualization: The decision to use HRT should be based on a woman's health and quality-of-life priorities, as well as her personal risk factors, such as risk for venous thrombosis, coronary heart disease (CHD), stroke, and breast cancer 1.
• Lowest effective dose: Women who decide to take HRT for the relief of menopausal symptoms should use the lowest effective dose for the shortest possible time 1.
• Specific hormone regimens: The quality of evidence on the benefits and harms of HRT varies for different hormone regimens, and most of the evidence comes from observational studies that did not differentiate among the effects of specific hormone preparations 1.
• Non-HRT alternatives: Clinicians should discuss with patients other effective strategies for preventing osteoporosis and fractures, such as screening for postmenopausal osteoporosis, hypertension, and lipid disorders, as well as counseling to promote a healthy diet and physical activity 1.

Key Considerations

• Benefits and harms: HRT has both benefits (e.g., increased bone mineral density, reduced risk for fracture and colorectal cancer) and harms (e.g., increased risk for breast cancer, venous thromboembolism, CHD, and stroke) 1.
• Phytoestrogens: The evidence is inconclusive on whether phytoestrogens (isoflavones such as iproflavone) are effective for reducing the risk for osteoporosis or cardiovascular disease 1.
• Bioidentical hormones: The FDA has not approved any type or class of bioidentical hormone therapy for the prevention of chronic diseases in postmenopausal women, and the safety and effectiveness of these products have not been evaluated through the FDA's drug approval process 1.

From the Research

Best Practices for Hormone Replacement Therapy (HRT) in Menopause

The following are best practices for HRT in menopause:

• The principal indication for HRT is the treatment of vasomotor symptoms, and benefits generally outweigh risks for healthy women with bothersome symptoms who elect HRT at the time of menopause 2.
• HRT should be individualized, based on a woman's medical history, needs, and preferences, and the lowest effective estrogen dose should be provided for the shortest duration necessary 2, 3.
• The effects of HRT on most organ systems vary by age and time since last physiologic exposure to hormones, and there are differences between regimens 4.
• For women with an intact uterus, estrogen will need to be combined with progestin or bazedoxifene (a selective estrogen receptor modulator - SERM) to minimize malignancy risk 5.
• Alternatives to HRT should be advised for women with or at increased risk for breast or endometrial cancer, cardiovascular disease, thromboembolic disorders, and active liver disease 2.

Contraindications and Risks

Contraindications to HRT use include:

• Breast or endometrial cancer
• Cardiovascular disease
• Thromboembolic disorders
• Active liver disease 2 Risks associated with HRT include:
• Increased risk of coronary heart disease, particularly in older women and those a number of years beyond menopause 2, 4
• Increased risk of breast cancer with extended use 2, 4
• Risk of stroke, cardiovascular disease, and venous thromboembolism 5

Treatment Options

Treatment options for menopausal symptoms include:

• Estrogen replacement therapy (ERT)
• Estrogen-progestogen therapy (EPT), which can be sequential or continuous combined 6
• Low-dose local estrogen therapy for vaginal symptoms 2
• Tibolone and the tissue-selective estrogen complex 6