Rethinking Menopausal Hormone Therapy: For Whom, What, When, and How Long?

Abstract

Menopausal hormone therapy (HT) was widely used in the past, but with the publication of seminal primary and secondary prevention trials that reported an excess cardiovascular risk with combined estrogen-progestin, HT use declined significantly. However, over the past 20 years, much has been learned about the relationship between the timing of HT use with respect to age and time since menopause, HT route of administration, and cardiovascular disease risk. Four leading medical societies recommend HT for the treatment of menopausal women with bothersome menopausal symptoms. In this context, this review, led by the American College of Cardiology Cardiolovascular Disease in Women Committee, along with leading gynecologists, women's health internists, and endocrinologists, aims to provide guidance on HT use, including the selection of patients and HT formulation with a focus on caring for symptomatic women with cardiovascular disease risk.

Keywords: cardiovascular diseases; coronary artery disease; hormone replacement therapy; hyperlipidemias; hypertension; menopause; venous thromboembolism.

Figure 1:

Timeline of HT use in US HT hormone therapy; HERS Heart and Estrogen/progestin Replacement Study; PEPI Postmenopausal Estrogen/Progestins Interventions; WHI Women’s Health Initiative;

Figure 2:

CEE+MPA and CEE-alone by age From the Women’s Health Initiative hormone therapy trials: absolute risks (cases per 10,000 person-years) for outcomes in the CEE+MPA and CEE-alone by age group. CEE, conjugated equine estrogens; MPA, medroxyprogesterone acetate. Modified from Manson JE JAMA 2013; 310:1535–68 (15)

Figure 3:

Menopausal hormone therapy recommendation by patient risk *Generally advised to avoid systemic HT. Consider alternative therapy and if severe VSM persists, individualized, shared decision making recommended. All women are candidates for low dose vaginal estrogen therapy for GSM. ASCVD atherosclerotic cardiovascular disease, CAD coronary artery disease, PAD peripheral arterial disease, TIA transient ischemic attack, MI myocardial infarction, HTN hypertension GSM genitourinary symptoms of menopause