New guidance on hormone therapy for menopausal women

New guidance clarifying cardiovascular and breast cancer risk of hormone therapy in women will help to assess whether it is safe for individuals to use this treatment to address bothersome menopausal symptoms, a Cleveland Clinic cardiologist advises.

The American College of Cardiology’s Cardiovascular Disease in Women Committee led by Cleveland Clinic’s Leslie Cho, MD, and in consultation with various organizations and experts in women’s health published their recommendations in the American Heart Association’s journal, Circulation, in mid-February. The guidance sets out the risks and benefits of hormone therapy; identify which women are appropriate candidates; and suggest how to minimize cardiovascular risks in women.

“Although many women with menopause-related symptoms can safely use hormone therapy, certain cardiovascular and non-cardiovascular conditions are relative or absolute contraindications for use,” says Dr. Cho. “It is important for doctors and patients to fully discuss the benefits and individual risks before patients choose to embark on hormone therapy. Their clinical condition and the dosage should also be reassessed regularly as the aim is to address life-limiting and bothersome symptoms with the lowest possible dose used for the shortest period of time necessary.”

Dr. Cho explains that some confusion exists currently as recommendations on hormone therapy have fluctuated significantly over the years as new research findings have been reported.

“In the 20th century, menopausal hormone therapy was widely recommended and used, reaching a peak in the late 1990s,” Dr. Cho explains. “However, when studies reported excess cardiovascular risk – and in particular, when the 2002 Women’s Health Initiative (WHI) trial was abandoned early due to the perceived risks involved – there was a dramatic decline in the use of hormone therapy worldwide. However, when the WHI results were later reviewed, researchers realized that younger women did not face the same cardiovascular risks as older women.”

As a result of subsequent research, we now know that cardiovascular risk varies depending on the timing of menopause, the initiation of hormone therapy, and the format in which it is administered, Dr. Cho adds.

The publications of the timelines is timely as according to the latest estimates from the World Health Organization, the global population of postmenopausal women is growing. Natural menopause in women generally between occurs between the ages of 45 and 55, and in 2021, women aged 50 and over accounted for 26% of all women and girls globally, increasing from 22% 10 years prior.

Symptoms and Risk Profiles

The new guidelines focus on addressing the vasomotor symptoms of menopause, which represent the most lifestyle-limiting symptoms and are the most common reason women present for care at the time of the menopause transition.

Vasomotor symptoms, including hot flashes and night sweats, occur in around 75% of women during the menopause transition, and are often associated with anxiety, sleep disruption, and reduced quality of life. Severe vasomotor symptoms can be treated through an estrogen-progestin combination. In contrast, genitourinary symptoms can be resolved with special low-dose estrogen creams which are not absorbed into the bloodstream and therefore have minimal risks.

In general, says Dr. Cho, the women who are safe to take hormone therapy are those who have just entered into perimenopause or menopause, who are of normal weight with normal blood pressure, who are physically active and who have a low risk of breast cancer, and a very low risk for having heart disease in the next 10 years as assessed by the various risk scores available in different countries.

Women with an intermediate risk include those with a health condition such as diabetes, obesity, high blood pressure, autoimmune diseases, high cholesterol, or metabolic syndrome, and those with lifestyle risks such as smoking, being sedentary or having limited mobility, and those with a higher 10-year risk for heart disease or a high risk for breast cancer.

Women with an existing cardiovascular condition – including congenital heart disease, blood clots, strokes and ‘mini-strokes’, for example – and women who have a high risk for breast cancer are among those deemed high-risk.

In conclusion, Dr. Cho says the recommendations also highlight the benefits of cardiologists working with experts from other medical field when addressing a patient’s menopausal symptoms, to streamline risk assessment, initiate appropriate menopause therapy and reduce the long-term cardiovascular risk.