Menopause management: return to hormone therapy

Hot flashes, night sweats and sleep disturbances are common symptoms of menopause that can affect health, quality of life and productivity at work.

A new review published in CMAJ (Canadian Medical Association Journal) recommends menopausal hormone therapy, historically known as hormone replacement therapy (HRT), as a first-line treatment in people without risk factors.

Menopausal symptoms can appear up to 10 years before the last menstrual period and last for more than 10 years, with negative effects for many people.

“Menopause and perimenopause can be associated with distressing symptoms and reduced quality of life,” writes Iliana Lega, MD, of Women’s College Hospital and the University of Toronto (Toronto, Ontario), along with other co-authors. “Menopausal hormone therapy is the first-line treatment for vasomotor symptoms in the absence of contraindications.”

The review summarizes the latest tests for diagnosing and treating menopausal symptoms, as well as the risks and benefits of therapies, to help clinicians and patients manage this condition.

“Although many treatments exist for menopausal symptoms, fear about the risks of menopausal hormone therapy and lack of knowledge about treatment options often deter patients from receiving treatment,” the authors write.

The benefits of menopausal hormone therapy include:

  • Reduction of hot flashes in up to 90% of patients with moderate to severe symptoms.
  • Improved blood lipid levels and possible reduced risk of diabetes.
  • Fewer fragility fractures of the hip, spine and other bones.

What are the risks?

Although previous evidence has shown an increased risk of breast cancer, the risk is much lower in people aged 50 to 59 years and those starting menopausal hormone therapy within the first 10 years of menopause.
Some studies show an increased risk of ischemic stroke in women over age 60 starting therapy 10 years after the onset of menopause, but the risk is low for those under age 60.

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For people with risk factors or those who don’t want to take menopausal hormone therapy, non-hormonal therapies, such as some selective serotonin reuptake inhibitors (SSRIs) and other medications, can help relieve symptoms.

“Despite initial concerns of an increased risk of cardiovascular events with menopausal hormone therapy following the Women’s Health Initiative study, increasing evidence shows a possible reduction in coronary artery disease with menopausal hormone therapy among younger menopausal patients, specifically those who begin menopausal hormone therapy before age 60 or within 10 years of menopause,” the authors write.

They emphasize that it is important for clinicians to ask about symptoms before and during menopause and discuss treatments with patients based on their personal preferences and potential risk factors.


A pragmatic approach to menopause treatment

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