There is so much confusion, fear and misinformation out there about HRT for symptomatic menopause that I thought I would take some time to outline the approach I use in my practice. I have a special interest in menopause management. As I publicly discuss, I am a breast cancer survivor, diagnosed at the age of 28. Due to treatment, I am in menopause. So I personally relate to my patients who suffer from menopause symptoms, and I am highly sensitive to issue related to breast health, genetics, and risks associated with hormones. The good news for women is that the current evidence based guidelines clearly state that many women who are symptomatic can be effectively and safely treated with hormones. The safety of hormone replacement therapy depends largely on the age of the patient and duration of use . For the majority of women, there risks are very few and the potential benefits are many when HRT is given for a clear indication and therapy is started WITHIN a few years of starting menopause.
The proven benefits are control of menopausal symptoms, maintenance of bone mineral density, and reduced osteoporotic fractures, improved muscle mss and strength. From a recent editorial of the Menopause Journal, ( Vol. 24 No. 9, 2017) :
"The evidence suggests that , for menopausal women aged younger then 60 years or within 10 years of menopause one, without contraindications, systemic HRT benefits outweigh risks for relief of menopause hot flashes and sleep disturbance and for prevention of bone loss"
In my practice, I always start with a comprehensive medical and family history, make sure that all preventative health care is up to date ( i.e. recent pap, pelvic exam, breast exam, mammogram, colonoscopy). I also asses the patients cardiac risk use things like blood pressure, cholesterol levels, and other factors to estimate their 10 year risk of heart attack or stroke. One online model I use is the Reynolds Risk
(www.reynoldsriskscore.org). It is important look at the total picture of health, including that patient's diet, fitness level, stress and emotional health. Finally, it is very important to find the menopause symptoms that most bother the patient. For some it is terrible hot flashes and night sweats. For others, the main symptom is mood changes and increase in anxiety. For other women, particularly women who are a bit beyond 2 years into menopause, it is vaginal dryness and painful intercourse. By identifying what the most troublesome symptoms are, we can target treatment. Some patients may need systemic hormone replacement therapy , most often in form of an estrogen patch. Women taking estrogen patches or pills also need progesterone ( preferably ) or a progestin. For women who only have vaginal dryness, there are many vaginal only treatments that do no require taking systemic hormones . The bottom line is that each patients management must be individualized to their own needs, risks, and goals.
In my next weekly post, I will try to separate fact from fiction and will explain potential risks to HRT and give some tips on how to balance the risks vs. benefits when deciding on HRT.
For more information, check out this excellent video from the North American Menopause Society.
Dr. Corinne Menn