North American Menopause Society Updates Its Position Statement on Hormone Therapy: 2017

Guideline Watch |
July 11, 2017

North American Menopause Society Updates Its Position Statement on Hormone Therapy: 2017

  1. Robert L. Barbieri, MD

Reaffirmation of HT's efficacy for managing vasomotor symptoms and genitourinary syndrome of menopause.

  1. Robert L. Barbieri, MD

Sponsoring Organization: The North American Menopause Society (NAMS)

Target Population: Women's healthcare providers

Background and Objective

Moderate to severe vasomotor symptoms (VMS) affect a high percentage of peri- and postmenopausal women. VMS may persist for many years, negatively affecting quality of life. Genitourinary syndrome of menopause (GSM) is also highly prevalent and may become more bothersome as women age. Using an evidence-based approach, an advisory panel of >20 experts updated the hormone therapy (HT) guidelines of the NAMS. Highlights include the following important clinical points.

Key Recommendations

Vasomotor Symptoms

  • Systemic HT is the most effective treatment for VMS.

  • Systemic HT has the most favorable benefit-risk ratio in women who are aged <60 or within 10 years of the onset of menopause. This ratio is optimal in women who do not have a uterus and are eligible for estrogen monotherapy.

  • For women aged ≥60 or >10 years from the onset of menopause, the benefit-risk ratio of HT is less favorable because of the greater absolute risk for coronary heart disease, stroke, venous thromboembolism, and dementia.

  • No evidence supports the routine discontinuation of HT at a specific age (e.g., 65).

  • For systemic HT, type, dose, duration, and route of administration should be individualized; shared decision making is recommended.

  • When prescribing systemic estrogen for women with an intact uterus, progestin or bazedoxifene is also recommended to prevent the development of endometrial hyperplasia or cancer.

Genitourinary Syndrome of Menopause

  • For women with isolated moderate to severe GSM who experience insufficient symptom relief with nonprescription lubricants and moisturizers, low-dose vaginal HT is recommended. This option has a superior benefit-risk ratio compared with systemic HT.

  • When using low-dose vaginal HT, progestin treatment to protect the endometrium is not necessary. If vaginal bleeding occurs, appropriate evaluation of the endometrium should be performed.

Premature Ovarian Insufficiency (POI)

  • For women with POI, HT is recommended until at least the median age of menopause, (i.e., age 52).

Bone Loss

  • Women with osteoporosis should be offered medical therapy to reduce risk for fracture.

  • For women aged <60 or within 10 years of the onset of menopause, HT may be considered a primary therapy for preventing additional bone loss and fracture. Other treatment options include bone-specific medications such as bisphosphonates.

Comment

The 2017 NAMS position statement reaffirms that HT is an effective treatment for both VMS and GSM. For management of VMS, my first-line HT regimen is a transdermal estradiol 0.037-mg patch plus a progestin taken either cyclically or continuously if the woman has a uterus. For women who do not have a uterus, I prescribe estrogen without progestin. Some observational evidence indicates that transdermal estradiol is associated with lower risk for venous thromboembolism compared with standard doses of oral estradiol. For GSM, my first-line HT option is a 10-µg vaginal estradiol tablet twice weekly. The FDA should remove or revise the current warning label for topical low-dose vaginal hormone products.

Note to Readers: Andrew Kaunitz, MD, Editor in Chief of NEJM Journal Watch Women's Health, served on the NAMS advisory panel but had no role in the selection or editing of this Guideline Watch.

Editor Disclosures at Time of Publication

  • Disclosures for Robert L. Barbieri, MD at time of publication Editorial boards UpToDate; OBG Management

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