The latest North American guidance on HRT treatment

In the summer of 2022 we were treated to new guidance from the North American Menopause Society for the use of menopause hormone therapy, aka MHT, aka HT (aka the treatment formerly known as but still often called HRT).

Keep in mind: this is a selection of official guidance from the body that advises physicians what to do.

It’s not cutting-edge research on promising areas, the kind that an integrative or functional physician might recommend. After all, research has shown that it can take up to 17 years for scientific findings to translate into medical advice doctors actually give.

So while we are hearing all sorts of talk of HRT for dementia prevention and cognitive health, anti-aging and longevity, better skin and more, NAMs isn’t making any such recommendations yet.

Recommended treatment for symptoms

  •  Hormone therapy remains the most effective treatment for hot flashes and night sweats. HT has been shown to prevent bone loss and fracture.
  • Vaginal estradiol is the most effective treatment for vaginal/vulva/urinary tract symptoms (aka genitourinary syndrome of menopause, or GSM).
  • Micronized, bioidentical progesterone (not progestogens, the synthetic form) without estrogen, at 300 mg nightly, significantly decreases hot flashes and night sweats compared with placebo and improves sleep.
  • Hormone therapy may be effective in improving cognitive function, but that effect may be more favorable in women who had normal cognitive function prior to starting it.
  • Estrogen therapy may have cognitive benefits when started immediately after a total hysterectomy, but when started soon after the natural menopause transition, the effects so far are neutral.

The jury is still out…

  • Estrogen therapy may benefit wound healing through a combination of reducing inflammation, stimulating new tissue to form and accelerating the migration of other epithelial cells required for the process.
  • Estrogen therapy appears to have beneficial effects on the thickness of skin layers, increases collagen and elastin and improves moisture when given at menopause, leading to fewer wrinkles.
  • There’s not enough research to say that estrogen can help reinstate thicker, fuller hair or prevent menopause-associated hair loss, even if that effect has been observed.
  • While there is some evidence that estrogen can reduce or mitigate some issues relating to eye health, there is so far a lack of good quality research.
  • The data on hormone therapy in relation to preventing hearing loss is observational and mixed.
  • Small studies have shown that hormone therapy can help dizziness, vertigo and balance issues associated with menopause.

Prevention

  • With HT, the evidence shows absolute risks are reduced for all-cause mortality, fracture, diabetes mellitus (estrogen and progesterone combined)
  • There isn’t enough evidence to recommend hormone therapy at any age to prevent a decline in cognitive function or dementia, and NAMs also says there isn’t enough evidence to recommend its use for treating cognitive decline, and dementia (Even as some anti-dementia protocols are recommending it). According to the Women’s Health Initiative Memory Study, starting hormone therapy in women over 65 actually raised their risk for developing dementia by 23 cases per 10,000 person years.

Risks + risk reduction

  • Benefits of HT outweigh risks for most healthy women with symptoms under 60 years as long as it’s started within 10 years of last period.
  • Lower doses of hormone therapy administered through the skin (patches, gels, sprays, rings and creams) lower the risk of blood clots and stroke.
  • Breast cancer risk does not increase appreciably with short-term use of estrogen-progestogen therapy and may be decreased with estrogen alone. (Progestogen is the umbrella term used for a class of synthetic or bioidentical or natural hormones that bind to the progesterone receptors. The evidence on the importance of using bioidentical progesterone over synthetic progestin is mounting)
  • Chronic unopposed exposure to estrogen increases the risk for thickening of the endometrium (lining of the uterus) and cancer. That is why progesterone (or synthetic progestin) must be prescribed along with estrogen, to prevent endometrial overgrowth. (Some things never change and this is one of them, and it’s important to point out. A percentage of women cannot tolerate progestogens and/or progesterone, and it’s tempting for them to skip it)

Prolonged use

  • There is a lack of randomized, controlled trial data about the risks of extended duration of hormone therapy in women above 60 or 65 years. (Watch out for experts and also “experts” on social media, no matter how many followers they have, who are advocating that it’s completely safe to take for the rest of your life.)
  • Observational studies suggest a potential rare risk of breast cancer with increased duration of hormone therapy.
  • Hormone therapy does not need to be routinely discontinued in women aged older than 60 or 65 years and can be considered for continuation beyond age 65 for persistent hot flashes and night sweats, quality-of-life issues, or prevention of osteoporosis after appropriate evaluation and counseling of benefits and risks. (This is somewhat of a contradiction to the first point and it ignores the second one. The key words are “routinely”, evaluation” and “counseling of benefits and risks”.)

HRT + cancer

  • A big shift from 2017 was the NAMS endorsement for low-dose vaginal estrogen therapy for symptoms of genitourinary syndrome of menopause for select survivors of breast and endometrial cancer. The latest guidance points to observational data suggesting low-dose vaginal estrogen therapy is safe and can greatly improve quality of life, although the authors point out non-hormone therapy should be the first route for treatment. In 2017, NAMS said this was a discussion for a patient and their oncologist, due to the “potential risk of small increases in circulating estrogens”.

HRT and POI

  • Women with primary ovarian insufficiency (POI) and premature or early menopause have higher risks of bone loss, heart disease, and cognitive or affective disorders associated with the too-early loss of estrogen. For them, NAMS recommends that hormone therapy be used until at least the average age of menopause, unless there is a contraindication. (This is of the utmost importance; for some reason this info appears not to filter down to doctors and we hear far too many cases of women who are left to suffer – and literally put their lives in danger – without HT. You can lose your hormones slowly as part of the peri/menopause transition and you might be fine, you might suffer, or be somewhere in between. The evidence clearly shows you cannot lose them all at once, years before you are meant to.)

If you decide to use hormone therapy…

  • NAMS recommends periodic, individualized assessment of the need for ongoing use of hormone therapy, and that it should be individualized on the basis of a woman’s menopause symptoms, general health and underlying medical conditions, risks, treatment goals, and personal preferences.

Ann Marie McQueen is the founder of Hotflash inc, a global platform to inform, inspire and entertain people in peri/menopause while bridging the gap between mainstream medicine and holistic care.

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