Update on menopausal hormone therapy

Abstract

In women around the perimenopause, it is logical to treat distressing symptoms and health sequelae of the menopause by oestrogen replacement. However, in view of the potential risks associated with long-term use of hormone replacement therapy (HRT), it should not be used as a universal panacea for all postmenopausal women. HRT is indicated for treatment of severe climacteric symptoms which significantly affect the quality of life for women who otherwise have no other medical contraindications for its use. Oestrogen has a role in the prevention and treatment of osteoporosis. HRT can prevent or delay the rate of bone loss. There is evidence from RCTs that HRT reduces both vertebral and non-vertebral fractures. There have been controversies on the effect oestrogen therapy on cardiovascular health. Although the Women’s Health Initiative study suggested an increase in coronary events in users of combined HRT, the subjects recruited in that study were of relatively older age (mean age 63) and the results may not be generalizable to the typical use of HRT in the early postmenopausal age. Based on current evidence, there is likely a benefit in cardiovascular protection if HRT is administered in women before 60 years of age and/or within 10 years of menopause (the “window-of-opportunity” hypothesis), which is endorsed in recent clinical guidelines. In view of the risks associated with its long term use, namely breast cancer, thromboembolism, stroke and gallbladder disease, it is now generally accepted that HRT should not be prescribed for the sole purpose of health prevention. Women with intact uterus who require HRT must take a combined preparation containing progestogen for endometrial protection. Cyclical (bleeding) and continuous (non-bleeding) regimens are available for combined HRT to suit the individuals’ circumstances and preferences. The cyclical regimen is recommended to women within two years of menopause to minimise the occurrence of breakthrough bleeding. Non-oral routes of administration generally may result in less metabolic and thromboembolic risks compared to oral administration. Treatment should be individualised with regard to the appropriate dose, duration, regimen and route of administration. For women with premature ovarian insufficiency before the age of 40 are generally recommended to take HRT till the average age at menopause in the general population. For vulvovaginal atrophic symptoms, use of lubricants, moisturizers and/or topical oestrogen may help. Topical oestrogen is more effective and has less systemic effects compared to systemic hormonal therapy for treatment of atrophic symptoms, and this may be continued as long as needed for symptom relief.