What are the indications and contraindications for Hormone Replacement Therapy (HRT) for menopausal symptoms?

From the Guidelines

Hormone therapy is indicated for managing moderate to severe menopausal symptoms, particularly vasomotor symptoms, and should be initiated at the lowest effective dose and continued for the shortest duration needed to control symptoms. The primary medications include estrogen-only therapy (ET) for women without a uterus, typically using estradiol 0.5-1mg daily or conjugated equine estrogens 0.3-0.625mg daily, and estrogen-progestogen therapy (EPT) for women with an intact uterus to prevent endometrial hyperplasia, using similar estrogen doses plus either cyclic progesterone 200mg for 12-14 days monthly or continuous medroxyprogesterone acetate 2.5mg daily 1.

Some key points to consider when prescribing hormone therapy include:

• Contraindications include current or history of estrogen-sensitive cancers (breast, endometrial), active liver disease, undiagnosed vaginal bleeding, history of venous thromboembolism, stroke, coronary heart disease, and known thrombophilias 1.
• Caution is warranted in women with migraine with aura, hypertriglyceridemia, active gallbladder disease, and increased risk of breast cancer 1.
• For women with contraindications or who prefer non-hormonal options, alternatives include SSRIs/SNRIs (paroxetine 7.5-25mg, venlafaxine 37.5-150mg), gabapentin (300-900mg daily), or clonidine (0.1-0.2mg daily) 1.
• Estrogen transdermal formulations may be preferred over other formulations due to lower rates of venous thromboembolism (VTE) and stroke 1.
• Micronized progestin may be preferred over medroxyprogesterone acetate (MPA) due to lower rates of VTE and breast cancer risk 1.

It's also important to note that:

• Local hormonal treatments can be used to treat vaginal dryness, and evidence suggests that local estrogen does not increase the risk of breast cancer recurrence 1.
• Vaginal estrogen preparations include rings, suppositories, and creams, and they have been shown to be effective for managing symptoms 1.
• Custom compounded bioidentical hormones are not recommended because data supporting claims that they are safer and more effective than standard hormones are lacking 1.

From the Research

Indications for Hormonal Treatment

• Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause 2
• HT is beneficial for preventing atherosclerosis and coronary heart disease (CHD) in healthy younger postmenopausal women (under the age of 60) 3
• HT prevents bone loss and osteoporosis, and reduces the overall mortality in women under 60 3, 4
• Women younger than 60 years or who initiate hormone therapy within 10 years of menopause onset gain short-term benefit in terms of symptomatic relief and long-term benefit in terms of protection from chronic diseases that affect postmenopausal women 4

Contraindications for Hormonal Treatment

• The risk of breast cancer depends on type of menopausal hormone therapy (MHT), duration of use, body mass, breast density, and interval between menopause and starting MHT 3
• The risks of venous thrombo-embolic disease (VTE), stroke, and coronary heart disease (CHD) depend on age on starting MHT, dose, nature, and route of administration of MHT 3
• MHT is not generally recommended in women over 60 because of the risks of VTE, stroke, and CHD 3
• Conjugated estrogens/bazedoxifene (CE/BZA) is not recommended for women with a history of venous thromboembolism or stroke 5

Special Considerations

• The timing of HT initiation, type and route of administration, and patient-specific considerations should be weighed when prescribing HT 2
• A simplified approach to MHT is suggested as a framework for the care of women at and after the menopause 3
• Progestin-only treatment may be effective for managing menopausal symptoms in women with contraindications to estrogens, but the optimal route and dosage have not been established 6