Hormone replacement therapy (HT) was widely used to treat menopause symptoms as recently as 20 years ago, but its use declined significantly in the last two decades because research showed it increased cardiovascular risks.
However, much has been learned since, showing that HT can be safely administered depending on the method used and the patient’s age, time since menopause, and risk of cardiovascular disease.
Those are the findings of a new review of medical literature just published in the journal Circulation, “Rethinking Menopausal Hormone Therapy: For Whom, What, When and How Long?,” from senior author Kathryn Lindley, MD, director of the Women’s Heart Center at VUMC. Lindley said HT can make a big difference in women’s quality of life; many have benefited from it, and many more could be good candidates who haven’t been considered.
“I think this paper is going to be a real resource for cardiologists,” said Lindley, associate professor of Medicine. “We wrote this manuscript with the cardiologist in mind to help them frame how to use and how to assess hormone replacement therapy for their patients. This paper brings in experts from cardiology, menopausal health, GYN and endocrinology to integrate information and determine a middle ground for approaching menopause.”
About 6,000 women in the nation enter menopause each day at a mean age of 52, the paper states, with common symptoms including hot flashes and night sweats, and are associated with anxiety, disrupted sleep and reduced quality of life. HT has proven effective in addressing those symptoms and became an increasingly popular therapy from the 1960s through the 1990s — topping out at 90 million HT prescriptions per year.
That plunged to about 20 million yearly HT prescriptions today after seminal primary and secondary prevention trials that showed an excess cardiovascular risk with combined estrogen-progestin.
Lindley’s review found that women with established cardiovascular risk — such as stroke or heart attack — should not receive HT, but those with low to moderate risk should be considered.
Generally, women are considered low risk if they are younger than 60 or within 10 years of the onset of menopause without cardiovascular risk factors such as high blood pressure, diabetes or obesity. Even women with moderate risk could be considered for HT, with appropriate cardiovascular monitoring, because the risks are low, and the quality-of-life benefits could be significant, Lindley said.
Lindley encourages women to consult their primary care physicians, OB-GYNs and cardiologists on the onset of menopause or, preferably, before. If they haven’t already, it is a good time to get a thorough cardiovascular evaluation to better understand their risk of cardiovascular disease and their individual risk of HT use.
“That is a time where we really need to be monitoring their weight, blood pressure, cholesterol and blood sugar so that we can identify changes in those risk factors and treat them very promptly,” Lindley said.
Lindley said the paper suggests an opportunity to better study the use of hormone replacement therapy in patients with cardiovascular risk factors, as the earlier seminal studies are now decades old.
“We really need to look at what symptoms the patients are having, what their overall risk is, and consider the tools available to us to safely provide them with some symptomatic relief,” she said.
