What is the role of Hormone Replacement Therapy (HRT) in treating vasomotor symptoms in postmenopausal women more than 10 years post-menopause?

From the Guidelines

Hormone replacement therapy (HRT) can be considered for treating vasomotor symptoms in women who are more than 10 years postmenopausal, but should be used at the lowest effective dose for the shortest duration necessary, as recommended by the most recent guidelines 1.

Key Considerations

• For women more than 10 years past menopause, the risks of HRT are somewhat higher than for those closer to menopause, particularly for cardiovascular events and stroke, as noted in previous studies 1.
• Thorough cardiovascular risk assessment is essential before initiating therapy, and treatment should begin with a 3-month trial to assess symptom improvement, with regular follow-up every 6-12 months to reevaluate the need for continued therapy.
• HRT works by replacing declining estrogen levels, which helps regulate the hypothalamic temperature control center and reduces the frequency and severity of hot flashes and night sweats.
• Non-hormonal alternatives like selective serotonin reuptake inhibitors (SSRIs) or gabapentin should be considered for women with contraindications to HRT, as suggested by recent guidelines 1.

Treatment Options

• A low-dose regimen is typically recommended, such as estradiol 0.5 mg daily orally, or a 0.025 mg transdermal patch changed twice weekly.
• If the woman has an intact uterus, progesterone must be added (such as micronized progesterone 100 mg daily or medroxyprogesterone acetate 2.5 mg daily) to prevent endometrial hyperplasia.
• Estrogen therapy alone (oral, transdermal, or vaginal) is recommended for women who have had a hysterectomy, as it has a more beneficial risk/benefit profile, as noted in recent studies 1.

From the FDA Drug Label

When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. Use of estrogen, alone or in combination with a progestin, should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman. For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible.

The role of Hormone Replacement Therapy (HRT) in treating vasomotor symptoms in postmenopausal women more than 10 years post-menopause is to control symptoms with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman.

• The treatment should be reevaluated periodically (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary.
• Attempts to discontinue or taper medication should be made at 3-month to 6-month intervals.
• The minimal effective dose for maintenance therapy should be determined by titration 2. However, there is no information provided about the long-term use of HRT (more than 10 years post-menopause) in the given drug labels.

From the Research

Role of Hormone Replacement Therapy (HRT) in Treating Vasomotor Symptoms

• HRT is recommended for the treatment of vasomotor symptoms (VMS), genitourinary syndrome of menopause (GSM), and the prevention of osteoporosis in postmenopausal women 3.
• The benefits and risks of HRT have been repeatedly verified and discussed, and determining how to take advantage of and control the risks of HRT by adjusting the initiation time, regimen, and duration is crucial 3.
• For symptomatic postmenopausal women under the age of 60 without contraindications, early initiation of HRT is safe and probably has a mortality benefit over the long term 3.

Considerations for HRT in Women More Than 10 Years Post-Menopause

• The current guidelines recommend that HRT in postmenopausal women with a uterus include a progestin to protect against endometrial hyperplasia, but concerns relating to HRT use appear to be related to the progestin component 4.
• Conjugated estrogens combined with the selective estrogen receptor modulator bazedoxifene is a new progestin-free HRT option for alleviating estrogen deficiency symptoms in postmenopausal women with a uterus for whom treatment with progestin-containing therapy is not appropriate 4.
• Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms and other symptoms of the climacteric, but benefits may exceed risks for the majority of symptomatic postmenopausal women who are under age 60 or under 10 years since the onset of menopause 5.

Individualized Therapy and Risk Assessment

• Health care professionals should individualize therapy based on clinical factors and patient preference, and screen women before initiating MHT for cardiovascular and breast cancer risk 5.
• The pooled cohort risk equation for atherosclerotic cardiovascular disease (ASCVD) and the free app named Menopro can be used to perform individual risk assessments 3.
• Utilizing a shared decision-making approach in regard to menopausal symptom management should aim to support women and help them maintain health and quality of life 6.

Alternative Therapies

• Chinese herbal medicines have benefits in alleviating hot flashes, depression, and menopausal symptoms, although further data are needed to strongly support their efficacy 3.
• Acupuncture and electroacupuncture have definite efficacy in the treatment of postmenopausal symptoms with few adverse effects, so they are a reasonable option as an alternative therapy for high-risk women 3.