What are the current guidelines for Hormone Replacement Therapy (HRT)?

Current Guidelines for Hormone Replacement Therapy (HRT)

HRT should not be routinely used for the primary prevention of chronic conditions in postmenopausal women, but should be used at the lowest effective dose for the shortest possible time when treating menopausal symptoms. 1, 2, 3

Benefits and Risks of HRT

Benefits:

• Reduces risk of fractures and osteoporosis 1, 2
• Relieves vasomotor symptoms (hot flashes) 4
• Improves vaginal atrophy and urogenital symptoms 4
• May reduce risk of colorectal cancer (with combined therapy) 1, 2
• Estrogen-only therapy may reduce risk of invasive breast cancer in women without a uterus 1

Risks:

• Combined estrogen-progestin therapy increases risk of:

  • Coronary heart disease events 1
  • Stroke 1, 2
  • Venous thromboembolism (deep venous thrombosis and pulmonary embolism) 1, 2
  • Breast cancer 1, 2
  • Gallbladder disease 1, 2
  • Urinary incontinence 1, 2
  • Probable dementia 1

• Estrogen-only therapy increases risk of:

  • Stroke 1
  • Deep venous thrombosis 1
  • Gallbladder disease 1
  • Urinary incontinence 1

Recommended Approach to HRT

Initial Evaluation:

• Comprehensive risk assessment focusing on cardiovascular health, breast cancer risk, and reproductive history 3
• Document complete gynecological history including age of menopause onset 3
• Review personal and family history of cardiovascular disease, venous thromboembolism, and stroke 3
• Document personal and family history of breast, endometrial, and ovarian cancer 3
• Evaluate smoking status 3

Prescribing Guidelines:

• For women with an intact uterus, progestin must be given in combination with estrogen to protect the endometrium 3, 5
• For women without a uterus, estrogen alone can be prescribed 5
• Use the lowest effective dose for the shortest duration consistent with treatment goals 5, 2
• Consider transdermal estradiol for women with hypertension or increased thrombotic risk 3, 4
• 17-β estradiol is preferred to ethinylestradiol or conjugated equine estrogens due to more favorable pharmacokinetic profile 3

Special Populations:

• Women with premature ovarian insufficiency (POI, menopause before age 40) should continue HRT until at least the average age of natural menopause 3
• HRT is generally contraindicated in breast cancer survivors 3
• For women with endometriosis who required oophorectomy, combined estrogen/progestogen therapy is recommended 3

Follow-up:

• Women using HRT should have a clinical review annually 3
• Patients should be reevaluated periodically (every 3-6 months) to determine if treatment is still necessary 5

Common Pitfalls to Avoid

• Initiating HRT solely for prevention of chronic conditions rather than symptom management 3
• Not considering transdermal estrogen for women with hypertension or increased thrombotic risk 3, 4
• Not discussing the modest but real risks of HRT with patients 3
• Failing to consider alternative therapies with potentially better safety profiles for menopausal symptom management 6
• Continuing HRT beyond the time needed for symptom relief 2, 5

Timing of HRT Initiation

• Age at starting HRT is critical in determining benefit/risk ratio 7
• When initiated within 10 years of menopause, HRT may reduce all-cause mortality and risks of coronary disease, osteoporosis, and dementias 7
• HRT initiated early after menopause may have cardiovascular benefits, but risks and benefits must be carefully weighed 3