Menopausal hormone therapy (MHT
or still referred to as hormone replacement therapy [HRT] by some) is an issue where standards have changed as additional research data has evolved. The Women’s Health Initiative (WHI) results, published in 2002, turned the conventional wisdom on this issue upside down. The number of women taking hormones for menopausal symptoms plummeted after the initial release of the WHI results, and current research suggests that use of MHT
remains lower than 2002 levels but is higher than the drop which occurred immediately after publication of the WHI data.
Although caution still exists on this topic, it is imperative that triage nurses educate themselves as to current research and supporting clinical recommendations that exist. For example, there is now strong clinical evidence that most women’s vasomotor symptoms will typically occur between the ages of 45 and 55 years, generally last 5 years or less, and that by age 60 years, the vasomotor symptoms of menopause will usually have resolved. Additionally, for those women who enter menopause (either naturally or as a result of surgery or other medical intervention) before the mean age of 51 years, most will become asymptomatic within 10 years. Some women will want to use some form of therapy until their vasomotor symptoms have resolved.
refers to the prescribing of estrogen, progesterone, or a combination of both. The hormones may be given continuously, meaning that the same doses of both estrogen and progesterone are used daily. The desired result with this regimen is amenorrhea. They may also be used in a cyclic fashion, with estrogen given throughout the month, and progesterone used to counteract the buildup of the uterine lining by taking it for part of the cycle. This results in a withdrawal bleed for most women.
The various hormones come in an array of delivery systems: pills, patches, topicals, rings, intrauterine devices (IUDs), and, rarely, injections. A patient may use one or a combination of delivery systems based on her preference or response to MHT
. Other hormones are occasionally added. In traditionally manufactured MHT
, the only hormone currently excluded is testosterone. Some compounded products have been under scrutiny by the U.S. Food and Drug Administration (FDA). They are beyond the scope of this text but may be utilized by practitioners with whom you work.
The term “bioidentical” is somewhat misleading and often associated with more “natural” hormones. All hormones, whether they are compounded or not, are manufactured from synthetic materials to mimic hormones naturally made by the body. The Endocrine Society Consensus Panel has recommended against using “custom compounded” MHTs that have not been approved by the FDA.
The most current evidence-based practice guidelines on the use of MHT
have been published by the Endocrine Society (2015) (see academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2015-2236
). These are updated regularly as newer research evidence develops, and they are an excellent source of information. The Endocrine Society guidelines emphasize the need to individualize treatment after accounting for a woman’s baseline cardiovascular risk, breast cancer risk, age, length of time since becoming menopausal, and personal preferences. The consensus panel has determined that MHT
is the most effective treatment for relief of vasomotor and other symptoms that are experienced in menopause. Consensus data on the use of MHT
shows some benefits in terms of reduction of anxiety and depressive symptoms, arthralgias, bone loss and fracture, diabetes, and dementia. However, all of these benefits are typically less than with utilization of other therapies, such as selective serotonin reuptake inhibitors (SSRIs) for anxiety and depressive symptoms; bisphosphonates for bone loss and fracture; and metformin, oral hypoglycemics, insulin, and other medications for diabetes.
Data have become increasingly strong that MHT
is generally safe to use if a woman is less than 60 years of age or is less than 10 years postmenopausal; is experiencing vasomotor symptoms that adversely affect her life; and does not have breast cancer, thromboembolic, or cardiovascular risk factors. Such low-risk patients are usually prescribed estrogen therapy (ET
) if they do not have a uterus or estrogen plus a progestin therapy (EPT
) if they still have a uterus. ET
may be given orally, via a transdermal patch, by vaginal ring, or by means of a transdermal cream or gel. Progestin may be delivered orally, by use of a cream or gel, or by means of an IUD
. Transdermal rings, gels, sprays, patches, and IUDs avoid the “first pass effect” that occurs when patients use oral medications, so the amount of hormone that is needed for symptom reduction is lower. For this reason, many providers will prescribe an ET
that is not delivered orally. Again, some patients prefer oral medications, and this is certainly a factor that may dictate the type of therapy that is selected.
For those women at risk for or who have cardiovascular disease, thromboembolic events, or breast cancer, current recommendations suggest use of a nonhormonal therapy (such as gabapentin, pregabalin, SSRIs, serotonin-norepinephrine reuptake inhibitors [SNRIs], or clonidine).
All women should be counseled on environmental measures that may greatly improve their vasomotor symptoms. Such interventions include dressing in layers, sleeping in athletic clothing that wicks away moisture, turning down the thermostat, reducing obesity, and avoiding alcohol and spicy foods. Unfortunately, evidence on the benefits of over-the-counter therapies is inconsistent. Benefits of black cohosh, red clover, vitamin E, omega-3 fatty acids, and other botanicals are not yet convincing either way. Similarly, some women have reported that acupuncture and yoga therapies are helpful, but the data is inconclusive in this regard as well.
In the case of vaginal or urogenital symptoms, local therapy should be considered first (e.g., creams, suppositories, rings). An oral therapy has also been approved for the treatment of vaginal dryness.
Some other important information for patients to know is that although MHT
is not thought to cause breast cancer, it may promote the growth of breast cancers that are already present. The risk is higher for women who use EPT
. In the WHI study, women who took estrogen alone did not show an increased risk of breast cancer, whereas women in the trial who took both estrogen and progesterone showed a slight increased risk.
In summary, there is perhaps no more controversial topic in women’s health than the subject of MHT
. Many women want to take MHT
due to symptoms and sometimes for “health reasons” that are not totally substantiated. As educators, the goal of all providers is to help the women they serve make informed choices. They need to recognize that “quality of life” is also an important measure of health which may conflict with conventional wisdom. Consequently, all providers need to be as factual and nonjudgmental as possible in advising patients on this controversial topic.