Menopausal hormone therapy (MHT) is an effective treatment that can be offered to most women with menopausal symptoms, following an appropriate assessment and using a shared decision-making process. Recent guidelines from the International Menopause Society recommend there is no need for a mandatory limit to the duration of MHT.
Menopausal hormone therapy (MHT) is the most effective treatment for menopausal symptoms.1,2 However, women and their doctors have been confronted with conflicting information about the risks of MHT rather than being provided with information about its benefits. In the wake of a new understanding of the risks and benefits, doctors can now confidently prescribe MHT to symptomatic women who have no contraindications.3 The timing of initiation and the type and route of administration are important in optimising benefits and minimising potential risks of MHT.
The menopause consultation
Women often present to their GP at menopause with a range of symptoms, including hot flushes and night sweats, joint and muscle pains, mood changes and genitourinary symptoms, usually with some change in the menstrual cycle. The consultation with a perimenopausal or menopausal woman should include exploring the woman’s concerns and reviewing her general medical history, with particular attention to cardiovascular disease and risk factors, cancer, osteoporosis and venous thromboembolism (VTE).4
This consultation is also a good opportunity to check that the woman is up to date with cervical screening tests and mammography, and to discuss healthy lifestyle choices. Measuring the level of follicle-stimulating hormone is not necessary if the woman has menstrual disturbance and is at the usual age of menopause (45 to 55 years). Blood tests are warranted in women younger than 45 years to confirm ovarian insufficiency and to rule out other causes of the symptoms and menstrual disturbance.
The decision to prescribe MHT should be a shared process, with the GP providing evidence to assist the woman to make a decision based on her personal circumstances and preferences. However, women with an early menopause (younger than 45 years) or a premature menopause (younger than 40 years) require especially careful assessment and support. MHT is recommended in these women until at least 51 years of age, in the absence of contraindications (Box 1).5-7 Following this, the decision about whether to continue with MHT should be made on the same basis as it is for other women of this age.
Remember that MHT is not a contraceptive. Contraception is recommended for two years after the final menstrual period in women under 50 years and for one year in those over 50 years.8
Benefits and risks of menopausal hormone therapy
Our understanding of the benefits and risks of MHT has evolved since the findings of the Women’s Health Initiative (WHI) trial were first published more than a decade ago.9 This trial reported increased risks of cardiovascular events, breast cancer and VTE in participants using MHT.
It is now largely agreed that not only were the claims of harm exaggerated, but that the findings have limited relevance to the typical perimenopausal or menopausal woman who is considering using MHT.2 The recently published long-term follow up of WHI participants found no difference in the rate of all-cause mortality between women randomised to MHT or placebo. Moreover, for women aged 50 to 59 years who were randomised to MHT, the hazard ratio for all-cause mortality during the intervention phase of the study was 0.69 (95% confidence interval [CI], 0.51 to 0.94).10 The International Menopause Society advises that MHT carries few risks when prescribed for symptomatic women without contraindications if initiated in women aged under 60 years or within 10 years of menopause.5
Despite the evident benefits of MHT in resolving menopausal symptoms and improving quality of life, women are often focused on the potential risks. These concerns should be addressed in a proactive fashion.
- Breast cancer. This is usually the foremost concern, especially since the results of the WHI study. In that study, oestrogen alone was associated with a decrease, rather than an increase, in breast cancer compared with placebo. The increase in breast cancer identified in the combined oestrogen–progestogen study equates in absolute terms to less than 1.0 case per 1000 women per year of use.5 Epidemiological data suggest that the risk is lower with progestogens other than medroxyprogesterone acetate.11
- Cardiovascular risk. If MHT is initiated within 10 years since the last menstrual period (LMP) or before the age of 60 years, coronary heart disease (death from cardiovascular causes and nonfatal myocardial infarction) is reduced by 48% (relative risk [RR], 0.52; 95% CI, 0.29 to 0.96; absolute difference, 7 per 1000 women). There is no clear evidence of an association with stroke in younger women.12
- Venous thromboembolism. The risk of VTE is heightened by obesity, smoking, increasing age and use of oral, but not transdermal, MHT (Box 2, Case 1).13