Hormone Replacement Therapy for Perimenopausal Symptoms: Risks and Benefits
HRT should be used primarily for managing menopausal symptoms at the lowest effective dose for the shortest possible time, not for prevention of chronic conditions, as the risks likely outweigh the benefits for most women. 1, 2
Benefits and Risks of HRT
- HRT is effective for managing vasomotor symptoms (hot flashes) and genitourinary symptoms in perimenopausal and menopausal women 1, 3
- For every 10,000 women taking estrogen and progestin for 1 year, there may be 7 additional coronary heart disease events, 8 more strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers 4, 1
- These risks are partially balanced against 6 fewer cases of colorectal cancer and 5 fewer hip fractures per 10,000 women per year 4, 1
- HRT increases the risk of gallbladder disease and cholecystitis (relative risk 1.8-2.5) 1
- Unopposed estrogen increases the risk of endometrial cancer in women with an intact uterus 1, 5
Decision-Making Algorithm for HRT
When to Consider HRT
- HRT is most appropriate within 10 years of menopause or under age 60 1, 2
- Higher risks are associated with initiation in women over 60 or more than 10 years past menopause 2, 6
- Women with moderate to severe vasomotor symptoms that impact quality of life are the best candidates 2, 3
Contraindications to HRT
- History of breast cancer 2
- Coronary heart disease 2
- Previous venous thromboembolic event or stroke 2
- Active liver disease 2
- Unexplained vaginal bleeding 5
Dosing and Administration
- Start with the lowest effective dose for symptom control 5
- For women with an intact uterus, estrogen must be combined with progestin to prevent endometrial cancer 5
- Women without a uterus can use estrogen-alone therapy 5
- Consider transdermal routes of administration as they have less impact on coagulation 2, 6
Important Considerations
- The U.S. Preventive Services Task Force recommends against using HRT for primary prevention of chronic conditions in postmenopausal women 4, 7
- Claims about superior safety of bioidentical hormones are not supported by scientific evidence 1
- Regular reassessment (every 3-6 months) is necessary to determine if continued treatment is needed 5
- Attempt to discontinue or taper medication at 3-6 month intervals 5
Common Pitfalls to Avoid
- Initiating HRT solely for prevention of chronic conditions like osteoporosis or cardiovascular disease 1, 2
- Continuing HRT for extended periods without reassessing the risk-benefit ratio 1
- Using unopposed estrogen in women with an intact uterus 1, 5
- Failing to distinguish between different HRT regimens and routes of administration, which can have varying risk profiles 2, 8
Shared Decision-Making Approach
- Discuss individual risk factors for cardiovascular disease, breast cancer, and osteoporosis 4
- Consider alternative non-hormonal therapies for symptom management when appropriate 9
- Inform patients that some risks (venous thromboembolism, stroke) occur within the first 1-2 years of therapy, while others (breast cancer) increase with longer-term use 4
- Discuss other effective strategies for preventing osteoporosis and fractures if that is a concern 4