Risks, Benefits, and Treatment Modalities of Menopausal Hormone Therapy: Current Concepts Original paper

What was studied?

The study reviewed menopausal hormone therapy (MHT), focusing on the risks, benefits, and treatment modalities related to managing menopausal symptoms like vasomotor symptoms (VMS) and osteoporosis. It evaluated different formulations, routes of administration, and the clinical impact of MHT on cardiovascular health, bone health, and the risk of conditions like breast cancer. The review highlighted how MHT’s safety and efficacy vary depending on timing, formulation, and patient health status, particularly in relation to the onset of menopause.

Who was studied?

The research examined women undergoing menopause, particularly those who are experiencing vasomotor symptoms, such as hot flashes and night sweats. The study included women within 10 years of menopause and those under 60 years of age, as this group tends to experience the most favorable outcomes with MHT. It also considered women with specific risks, including those with obesity, hypertension, or cardiovascular concerns, and assessed their response to both estrogen-only and combined estrogen-progestogen therapy. In addition, the study touched on the effects of MHT in older women and in those with a history of breast cancer or other estrogen-sensitive conditions.

Most important findings

The study found that MHT remains the most effective treatment for vasomotor symptoms, with significant improvements in the frequency and severity of hot flashes and night sweats. The review highlighted that early initiation of MHT, particularly within 10 years of menopause, has a favorable impact on cardiovascular health and bone health. The timing hypothesis suggests that initiating MHT closer to menopause may help reduce the risk of coronary artery disease and improve lipid profiles. The risks associated with MHT, including cardiovascular events and breast cancer, tend to increase with age and the duration of hormone use. Notably, transdermal estrogen was found to have a lower risk of venous thromboembolism and stroke compared to oral forms. For women with an intact uterus, progestogen therapy is necessary to prevent endometrial hyperplasia and cancer. The review also examined vaginal estrogen for genitourinary symptoms and found that it is effective for treating vaginal dryness and discomfort, with minimal systemic absorption. The overall benefit-risk profile of MHT is most favorable when it is used early in menopause and for women without contraindications such as a history of estrogen-sensitive cancers.

Key implications

Clinicians should tailor MHT based on the patient’s age, timing since menopause, and risk profile. Transdermal estrogen is preferred for women with cardiovascular risks as it avoids first-pass metabolism, reducing the risk of thrombotic events. Progestogen should be added to estrogen therapy in women with a uterus to prevent endometrial cancer. Non-hormonal treatments are an option for women who cannot use hormones or prefer alternatives, and these may include medications like SSRIs/SNRIs and gabapentinoids. Vaginal estrogen remains the most effective treatment for genitourinary symptoms. For women under 60 or within 10 years of menopause, MHT provides substantial benefits in managing symptoms and preventing osteoporosis, while minimizing risks when used appropriately. The clinical decision to start, continue, or discontinue MHT should involve shared decision-making between the clinician and patient, incorporating lifestyle changes and regular monitoring for cardiovascular health and breast cancer risk.