Facts About Menopausal Hormonal Therapy

10 years after the publication of the Women’s Health Initiative trials data¹, certain facts and data have emerged that can help guide us in this so controversial an issue of Menopausal Hormonal Therapy (MHT). The following is a summary of a review published lately in the journal Menopause².

It has always been a truth that MHT is an acceptable option for treating severe early menopausal symptoms. As is the wont of these symptoms, they disappear within 10 years of menopause, thus this treatment is prudent and applicable within this time frame. Such therapy must of course be precluded in the presence of medical problems, foremost of which are blood clots, heart disease, stroke and cancer.

Estrogen replacement alone suffices for a woman who has lost her uterus, whereas progesterone therapy needs to be added for the sole purpose of prevention of endometrial cancer in those who retain theirs. If the symptoms are limited to the vulva, vagina and the bladder, topical estrogen therapy to the affected parts might be enough to soothe the symptoms.

So much is so true, and we must keep in mind that the whole controversy arose not because of questionable beneficial effects, rather, the serious consequences of MHT. Foremost in the mind of most women is the occurrence of breast cancer. The WHI trials demonstrated an increased risk of breast cancer with more than 5 years continued use of the estrogen-progesterone combination therapy. This increased risk was not present in users of estrogen-only preparations, thus suggesting a causal link of breast cancer with progesterone. The data shows that the risk is not that great and decreases after discontinuation of said replacement therapy. Estrogen, whether given alone or together with progesterone, increases the risk of thromboembolic events (TE) such as deep vein thrombosis, pulmonary embolism and stroke, but these occurrences are rare before the age of 59 years.

Thus we have come to accept that combination estrogen-progesterone MHT is proven effective in the management of early menopausal symptoms only (and not for other indications) but should be used for the shortest duration and with the lowest possible dosage. More flexibility is accorded to estrogen only therapy but similar caveats should apply whenever possible.

1. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA 2002;288(3):321-333.

2. Stuenkel CA, Gass MLS, Manson J et al. A Decade After the Women’s Health    Initiative – The Experts Do Agree. Menopause 2012;19(8):846-847.