The North American Menopause Society (menopause.org) recently published an updated 2017 position statement on the risk/benefit use of hormone therapy (HT). In my last article, I reviewed hormones effects on hot flashes, bone health, genitourinary health, sexual function, sleep, skin and hair. If you missed this article visit my website leachobgyn.com. This month I will review HT effect on mood & cognition, cancer, and cardiovascular morbidity and all-cause mortality.
Mood/Depression/Cognition: For postmenopausal women without clinical depression, evidence is mixed concerning the effects of HT on mood, with small, short-term trials suggesting that HT improves mood, whereas others show no change. Randomized controlled trials (RCT) are the gold standard when evaluating the efficacy of medicine as a treatment for a specific problem, and three large RCT’s demonstrate neutral effects of HT on cognitive function. In the absence of more definitive findings, HT cannot be recommended at any age for the primary treatment of mood disorders like anxiety and depression or prevent a decline in cognitive function or reduce the risk for dementia.
Cardiovascular disease and all-cause mortality: Newer observational data and reanalysis of older studies by age or time since menopause, including the WHI from 2002, suggest that for healthy, recently menopausal women, the benefits of HT (estrogen alone or with progesterone) outweigh its risks, with fewer cardiovascular events in younger vs older women. You will have to remember that the average age of women in the 2002 WHI trial was 63 years, and that initiating HT in younger symptomatic menopausal women (~early 50’s) is not the same risk/benefit ratio as starting HT in women who are in their early 60’s or more then 10 years since menopause. HT represents a safe and effective option for the treatment of menopausal symptoms like hot flashes, when initiated in healthy postmenopausal women aged younger then 60 years or are within 10 years of menopause onset. Summary of several RCT’s report a significant reduction in all-cause mortality in symptomatic women who initiate HT when aged less then 60 years (timing hypothesis) and/or are within 10 years from menopause onset. Women who initiate HT older then 60 years, and/or who are more than 10 years, and clearly by 20 years, from menopause onset are at higher risk for cardiac events, blood clots, and stroke compared to younger women initiating HT.
Cancer: The initiation of HT in breast cancer survivors (especially estrogen receptor positive) is generally not advised. The effect of HT on breast cancer risk depends on the type of HT (estrogen alone or estrogen + progesterone), dose, route of administration, duration of use, regimen, prior exposure, and individual patient characteristics. It is not easy to give this a simple thumb up or down, but rather using HT is nuanced and every patient has her own unique set of variables that makes that decision very individualized. With respect to endometrial cancer, it is without question that unopposed systemic estrogen in postmenopausal women with an intact uterus increases the risk of endometrial cancer. This is why a woman with a uterus should always be on a balanced regimen of estrogen + progesterone. There are no convincing data that estrogen initiates or promotes ovarian cancer. Observational trials suggest a reduced risk or colorectal cancer in HT users, particularly if initiated early in menopause. There appears to be an overall neutral effect of HT on lung cancer.
In summary, in the 15 years since the publication of the WHI trial on HT use in menopausal women, much has been learned, yet much controversy remains. What is now clear, individualization with shared decision making remains key along with periodic reevaluation to determine an individual woman’s unique benefit-risk profile. Having this discussion with a certified menopausal practitioner, gives you the best margin for safety. Call for an appointment if you have questions.