The North American Menopause Society (NAMS) recently released its 2022 Guidelines for Hormone Therapy, an update to its 2017 statement that includes significant additions based on the most current scientific evidence. To provide comprehensive and verified guidelines, NAMS recruited an Advisory Panel of experts in the field to review its 2017 Position Statement, evaluate new literature, assess the evidence, and develop updated recommendations.
The 2022 Hormone Therapy Position Statement reflects the latest research findings and recommendations, further clarifies the balance of risks and benefits of hormone therapy, and provides guidance on additional aspects of health care management relevant to patients experiencing menopause symptoms.
It is important to note that there was no change in NAMS’ overall position on hormone therapy, which is that it “remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture.”
The Society emphasized important clinical considerations that can be applied to various therapeutic interventions. Namely, the key to safe, effective care is a personalized approach to treatment with shared decision-making and patient involvement. In addition, patients need to be reevaluated periodically to determine their individual risk-to-benefit ratio throughout treatment, which should be tailored according to the appropriate dose, duration, and route of administration to manage symptoms and meet treatment goals.
2022 Statement Highlights
The updated Position Statement offers additional recommendations for clinicians to help guide hormone therapy in the safest way for optimal results. Some of the key points are highlighted below:
- Hormone therapy significantly reduces the diagnosis of new-onset type 2 diabetes mellitus, but it is not approved for this indication.
- Longer duration therapy should be documented for indications with shared decision-making and periodic reevaluation.
- Low-dose vaginal estrogen therapy for the treatment of genitourinary symptoms appears safe and effective for select survivors of breast and endometrial cancer.
- Non-estrogen alternatives that have been FDA-approved for dyspareunia include ospemifene and intravaginal DHEA.
- Risk stratification for hormone therapy should be done considering age and time since menopause.
- Patients who begin hormone therapy after the age of 60 years or more than 10 or 20 years from menopause onset experience higher absolute risks of coronary heart disease, venous thromboembolism, and stroke those women initiating hormone therapy in early menopause.
- Breast cancer risk does not increase significantly with short-term use of estrogen-progestogen therapy and may be decreased with estrogen therapy alone.
- The risk of gallstones, cholecystitis, and cholecystectomy is increased with estrogen and estrogen-progesterone therapies.
- Transdermal routes of administration and lower doses of hormone therapeutics may decrease the risk of venous thromboembolism and stroke.
Evaluating Benefits and Risks
One of the most important clinical considerations for administering hormone therapy is each patient’s risk-to-benefit ratio. According to NAMS, “the benefits of hormone therapy outweigh the risks for most healthy symptomatic women younger than 60 years and within 10 years of menopause onset.”
In female patients with primary ovarian insufficiency and premature or early menopause with a heightened risk of bone loss, cardiovascular disease, and cognitive or affective disorders, hormone therapies can be administered until at least the mean age of menopause, barring any contraindications.
The 2022 Hormone Therapy Position Statement framework is by no means an endpoint but rather a tool to guide clinicians and their patients through shared decision-making. The document is grounded in current evidence about the risks and benefits of hormone therapies, but treatment and care must be conducted within the context of individualized risk-to-benefit ratios.
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