Menopausal Hormone Therapy: Balancing Risks and Benefits

Despite significant advances in understanding menopausal hormone therapy (MHT), outdated research continues to influence patient and clinician perceptions. Over the past 70 years, MHT's reputation has fluctuated dramatically, initially celebrated for cardiovascular benefits, then scrutinized for potential risks. Recent studies, however, provide a more nuanced view, emphasizing its health and lifestyle benefits when started earlier.

The Evolution of Menopausal Hormone Therapy

MHT, also known as hormone replacement therapy (HRT), was once widely regarded as beneficial for reducing cardiovascular risks, improving bone health, and aiding weight management, with breast cancer as the primary concern. This perception changed drastically in 2002 with the release of the Women's Health Initiative (WHI) study, which reported increased risks of breast cancer and cardiovascular disease in women undergoing MHT.

Professor Bronwyn Stuckey from the University of Western Australia explains that the WHI study's initial interpretations caused widespread alarm. The study suggested increased cardiovascular risks across all age groups, which led to a significant decline in MHT use. However, further analysis revealed that the heightened cardiovascular risk was primarily in women who started continuous combined HRT more than 20 years after menopause.

In 2007, a more detailed examination of WHI data highlighted the differences between estrogen-only and estrogen plus progestogen (E+P) therapies and the importance of timing. This nuanced understanding has been supported by additional studies over the years, reshaping the approach to MHT.

Current Perspectives on MHT

Dr. Anna Clare, a councillor for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, notes that recent research, including a 15-year follow-up to the WHI study, reassures clinicians and patients. This follow-up showed no increased risk of cardiovascular or all-cause mortality with MHT. Starting hormone therapy around menopause is now considered safer, with potential cardiovascular benefits.

Despite this, outdated information in medical indexes and guidelines has slowed the integration of these findings into clinical practice. Professor Stuckey emphasizes several key points:

1. No Stopping Rules: MHT can continue as long as there is a medical indication.

2. Effective Osteoporosis Treatment: Estrogen is effective in preventing fractures, comparable to drugs like bisphosphonates and denosumab.

3. Flexible Timing: While starting MHT early may offer greater cardiovascular benefits, it can still significantly improve quality of life and manage symptoms even if started later.

Quality of Life and Broader Benefits

When discussing MHT with patients, it's essential to weigh the risks and benefits. MHT's role in preserving bone density, reducing the risk of type 2 diabetes, and improving quality of life is crucial. This is particularly relevant as more menopausal women remain active in the workforce and leadership roles, supported by public figures like Michelle Obama and Davina McCall advocating for menopause awareness.

Dr. Clare highlights that robust safety data now allows women to manage menopausal symptoms without undue fear, improving their quality of life. A personalized approach to MHT is vital, considering factors like uterus status, risk of venous thrombosis, and sensitivity to hormonal changes.

Personalized Treatment Approaches

Professor Stuckey underscores the importance of tailoring MHT to individual needs. For example, women without a uterus may avoid progestogen due to its associated breast cancer risk. Transdermal estrogen is preferred for those at risk of venous thrombosis or sensitive to hormonal fluxes. Additionally, women close to their last menstrual period may benefit more from cyclical rather than continuous combined MHT.

Choosing the right MHT formulation is akin to trying on a dress—what works for one person may not suit another. This personalized approach ensures that women receive the most effective and safe treatment for their unique circumstances.

By embracing updated research and adopting a personalized approach, clinicians can help women navigate menopause with confidence, improving their health and quality of life.