New hormone therapy guidelines from the North American Menopause Society

The North American Menopause Society (NAMS) published its 2022 hormone therapy position statement in Menopause on July 7, 2022.¹ The new guidelines considered and incorporated the most recent research and literature published since the previous statement in 2017.²

“Since our last Position Statement,” said Stephanie S. Faubion, NAMS medical director and lead of the Position Statement Advisory Council, “there have been important additions that further clarify the balance of risks and benefits of hormone therapy options for menopause symptoms.” What hasn’t changed, according Faubion, is hormone therapy’s effectiveness as treatment for vasomotor symptoms (VMS) and genitourinary syndrome of menopause (GSM), as well as its use for bone loss and fracture prevention.

The 2022 recommendations reiterate the importance of shared decision-making and patient education when addressing treatment options, stating that—for most healthy, symptomatic women under the age of 60 who are within 10 years of menopause onset—the benefits of hormone therapy outweigh the risks.

The new statement includes the following general, age- and condition-specific recommendations:

• Use shared decision-making to develop personalized treatment plans.
• Conduct periodic reevaluation of a woman’s benefit-risk profile and risk stratification by age and time since menopause.
• Recommend and remind patients of the appropriate dose, duration, regimen, and route of administration required to manage symptoms and meet treatment goals.
• Transdermal routes of administration and lower doses of hormone therapy may decrease risk of venous thromboembolism and stroke.
• Women with primary ovarian insufficiency and premature or early menopause have higher risks of bone loss, heart disease, and cognitive or affective disorders associated with estrogen deficiency. Hormone therapy can be used until at least the mean age of menopause unless contraindications present.
• Short-term estrogen-progestogen use does not significantly increase breast cancer risk and may be decreased with estrogen alone.
• In women aged older than 60 or 65, hormone therapy does not need to be routinely discontinued. It can be considered for continuation beyond age 65—after appropriate evaluation and benefits-risks counseling—for persistent VMS, quality-of-life issues, or osteoporosis prevention.
• For women with GSM, vaginal estrogen (and systemic if required) or other nonestrogen therapies may be used at any age for extended duration, if needed.

The statement also reported on observational data that suggested low-dose estrogen therapy to be safe for GSM treatment in women with breast and endometrial cancer who failed nonhormone therapy, and beneficial for addressing quality-of-life issues.

While randomized, controlled trial data about the risks involved with extended duration of hormone therapy are scarce, some observational studies suggested a potential—but rare—risk of breast cancer.

The statement also outlined several safety concerns with compounded bioidentical hormone therapy:

• Minimal government regulation and monitoring,
• Over- and under-dosing,
• Presence of impurities or lack of sterility,
• Lack of scientific efficacy and safety data,
• And lack of outlined risks on labels.

To read the full 2022 position statement and find practical patient resources, visit menopause.org.

References

1. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause (New York, NY). 2022;29(7):767-794. doi:10.1097/GME.0000000000002028
2. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause (New York, NY). POSITION STATEMENT. doi:10.1097/GME.0000000000000921