Paging Dr. Frischer: Menopausal Hormone Therapy

When I first started practicing medicine, it was very common for women who reached menopause to go on hormone replacement therapy (HRT) to relieve symptoms and prevent osteoporosis. Some studies then suggested that it would also help to prevent heart disease.

This changed abruptly in 2002 when the Women’s Health Initiative study was published. It found a link between HRT and an increased risk of blood clots, stroke, and breast and ovarian cancer. The results were complex: These and other conditions behave differently depending on the form of HRT, whether hormones are started around the time of menopause rather than later, and even the weight of the patient.

These 2002 findings on heart disease and breast cancer in women led to a sudden and marked reduction in the use of HRT, and subsequently to a significant drop in breast cancer rates. However, it also led to more women having to endure the often-debilitating symptoms of menopause and perimenopause.

Time passed. HRT is now referred to as menopausal hormone therapy (MHT). In 2022, the North American Menopause Society (NAMS) published a new position statement on MHT. Instead of issuing broad restrictions, the new recommendations state that the risks and benefits of hormone therapy should be discussed with each individual, and that the decision to use or not use MHT should be based on age, medical history, existing medical conditions and medications, and the severity of the symptoms. The data suggests that when MHT is started before the age of 60, or within 10 years of menopause without any medical contraindications, the benefits of MHT actually outweigh the risks.

Just what are those benefits? For some, the symptoms of menopause greatly affect quality of life, and can include hot flashes, night sweats, vaginal dryness and painful sex, weight gain, depression, joint pain, mood changes, insomnia, inability to concentrate, and a decreased sex drive. In addition to alleviating many of those symptoms, MHT may also protect against bone loss and fracture, lower the risk of diabetes and heart disease, prevent or reduce urinary tract infections, and relieve dry skin, nails, and eyes.

What are the potential risks of MHT? There is indeed a slightly increased risk of breast cancer: Less than one additional case of breast cancer occurs per 1,000 women per year of MHT use. This increases after five years of use. Women older than 60 or who begin MHT more than 10 years after the onset of menopause have a greater risk of blood clots, which can be fatal. The risk of heart disease and stroke can increase. Some of these risks are reduced with lower doses, and with the use of transdermal delivery methods rather than oral pills.

For some women, the risks of using MHT may still be too high, including those with a history of liver disease, heart disease, stroke, heart attack, blood clots, inherited history of increased risk for blood clots, or a personal history of estrogen-sensitive cancer.

However, benefits from menopausal hormone therapy may well outweigh risks for those who are healthy and have moderate to severe hot flashes, have other significant symptoms of menopause, need to prevent bone loss or fracture, experience early menopause, or have certain estrogen deficiencies.

To determine if hormone therapy is a good treatment option for you, speak with your doctor about your individual symptoms and health risks. This science is evolving rapidly, and as more is learned about hormone therapy and other menopausal treatments, these recommendations will continue to change.