Understanding the risks and benefits of hormone therapy for menopause

Hormone therapy (HT) is a common treatment for managing menopause symptoms, but understanding its risks and benefits is essential for proper patient care. Stephanie Faubion, MD, MBA, medical director of The Menopause Society, emphasized the importance of identifying contraindications and assessing individual risk factors during her presentation at the 2024 Annual Meeting of The Menopause Society.

According to Faubion, "It was all about hormone therapy risks and benefits and understanding what those are. It was about really identifying the contraindications, which are few. They are a history of stroke, a history of heart attack, a history of hormone-sensitive cancers like breast or endometrial cancer, a history of blood clot, and unexplained vaginal bleeding, which is my favorite, because it shouldn't be unexplained for very long." Once these contraindications are ruled out, most women under 60 years of age and within 10 years of menopause onset who have significant vasomotor symptoms are considered good candidates for hormone therapy.

Cardiovascular health is a critical factor to consider when prescribing HT. Faubion explains, "We need to consider cardiovascular disease risk, and we can use the ASCVD Risk Calculator to inform us on that." Cardiovascular disease becomes particularly relevant because, as Faubion pointed out, about 80% of women aged 55 years or older have at least one chronic medical condition, and 50% have two or more. Common conditions include hypertension, obesity, and impaired fasting glucose, which must be taken into account when deciding whether to prescribe HT and determining the appropriate route of administration.

One important takeaway is the difference in breast cancer risk based on the type of hormone therapy. Faubion highlighted that "the risk is different if you're using estrogen alone in women who have had a hysterectomy or the combination of estrogen plus a progestogen in those women who have a uterus." She added that, according to data from the Women’s Health Initiative, the use of estrogen alone does not seem to increase breast cancer risk, while combination therapy may lead to "a little less than one additional case per 1000 women per year after about five years of treatment."

Another significant benefit of hormone therapy is its positive effect on bone health. Faubion noted, "It will reduce the loss of bone around the menopause transition, so it reduces fracture risk, prevents bone loss." However, when it comes to cognitive health, the data are more neutral. Starting hormone therapy under the age of 60 and within 10 years of menopause onset poses no harm, but likely no cognitive benefit either.

Faubion emphasized the importance of reassessing HT regularly, stating, "Hormone therapy and the use of hormone therapy should be reassessed on a regular basis. We don't just send people off into Never Never Land and say, 'Have a nice life.' Instead, it needs to be monitored on a regular basis, like at least once a year." Additionally, she advised that discontinuation of hormone therapy should not be based on age alone but rather on individual patient needs and risk factors.

Ultimately, hormone therapy can significantly improve the quality of life for many women, particularly those experiencing persistent menopausal symptoms that do not respond to other treatments. As Faubion noted, "Some women do just fine, not on hormone therapy. Some women have recurrent symptoms, roughly about 50% of women will have recurrent symptoms when they stop." The decision to continue or discontinue HT should be based on an individualized risk-benefit analysis as women age and accumulate more chronic conditions.