What is the role of Hormone Replacement Therapy (HRT) for managing perimenopausal symptoms?

From the Guidelines

Hormone replacement therapy (HRT) is an effective treatment for perimenopausal symptoms, and the most recent evidence suggests that it should be used at the lowest effective dose for the shortest duration necessary to alleviate symptoms. For women experiencing hot flashes, night sweats, mood changes, and vaginal dryness during perimenopause, a combination of estrogen and progesterone is typically recommended, as seen in studies such as 1. Common regimens include oral estradiol (1-2 mg daily) or estradiol patches (0.05 mg/day) combined with either cyclic progesterone (200 mg for 12-14 days per month) or continuous micronized progesterone (100 mg daily) for women with an intact uterus. Progesterone is essential to prevent endometrial hyperplasia.

Some key points to consider when prescribing HRT include:

• Treatment should start at the lowest effective dose and can be adjusted based on symptom response.
• For women who have had a hysterectomy, estrogen-only therapy is appropriate.
• Topical vaginal estrogen (creams, rings, or tablets) can be used specifically for vaginal symptoms with minimal systemic absorption.
• HRT works by replacing declining hormone levels, which helps regulate body temperature, mood, and maintains vaginal tissue health.
• Treatment duration should be individualized, but generally limited to 5 years or less for systemic therapy due to potential risks including blood clots, stroke, and breast cancer, which increase with longer use, as noted in studies such as 1 and 1.
• Regular follow-up with a healthcare provider is necessary to monitor benefits and risks.

It's also important to consider alternative approaches to prevention, such as weight-bearing exercise and other effective interventions for treating women with low bone density, as mentioned in 1. Ultimately, the decision to use HRT should be based on a woman's individual clinical situation, preferences, and values, with the goal of maximizing benefits while minimizing harms.

From the Research

Hormone Replacement Therapy (HRT) for Perimenopausal Symptoms

• HRT is a common treatment for managing perimenopausal symptoms, including hot flashes, night sweats, and genitourinary symptoms 2, 3.
• The benefits of HRT in improving menopausal symptoms are well-established, with systemic estrogen alone or combined with a progestogen reducing the frequency of vasomotor symptoms by approximately 75% 3.
• Different forms of HRT are available, including oral and transdermal estrogen, as well as bioidentical estrogens approved by the US Food and Drug Administration 3.

Types of HRT

• Combined estrogen and progestogen therapy is commonly used to treat perimenopausal symptoms, with conjugated equine estrogens (CEE) with or without medroxyprogesterone acetate (MPA) being one of the most studied combinations 3.
• Progestin-only therapy has also been investigated as a treatment for menopausal symptoms, with some studies suggesting that it may be effective in improving vasomotor symptoms, but not mood symptoms 4.
• The choice of progestin may affect the efficacy and tolerability of HRT, with dienogest being associated with improved psychological symptoms compared to medroxyprogesterone acetate 5.

Efficacy and Safety of HRT

• HRT has been shown to be effective in reducing the frequency and severity of perimenopausal symptoms, including hot flashes and night sweats 2, 3.
• However, HRT is also associated with potential risks, including an increased risk of stroke, venous thromboembolism, and breast cancer 3.
• The risks and benefits of HRT should be carefully considered for each individual woman, taking into account her medical history, risk factors, and personal preferences 2, 3.

Alternative Treatments

• Nonhormonal treatments, such as selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs), may be effective in reducing vasomotor symptoms in women who are not candidates for HRT or prefer not to use it 3.
• Low-dose vaginal estrogen and vaginal prasterone may also be effective in improving genitourinary symptoms in perimenopausal women 3.