Reassessing Hormone Support for Midlife Women

The topic of reassessing menopausal hormone therapy (MHT) for women is complex and has evolved significantly over the years since publication of the initial findings of the Women’s Health Initiative Study.

Unfortunately for many women (not all), this new data has not been incorporated into their healthcare strategies by their providers

Here are some key points to consider with your midlife health and MHT.

Historical Context

  • Women's Health Initiative (WHI) Study: Published in the early 2000s, the WHI study had a significant impact on MHT practices. It reported increased risks of breast cancer, heart disease, stroke, and blood clots with combined oral estrogen-progestin therapy. This led to a dramatic decline in MHT use. But we do not use these medications anymore and we now know that there is a critical time period to start MHT when it is safer and more effective for disease prevention. Despite this, physicians and policy makers still hold on to this antiquated study of medications we no longer recommend.

  • Re-evaluations and Criticisms: Subsequent analyses and critiques of the WHI study have highlighted that the initial findings were overstated and misinterpreted. Factors such as the age of participants and timing of therapy initiation have been found to play crucial roles in the risks and benefits of MHT.

Current Evidence: Moving Beyond the WHI

  • Individualized Approach: A modern approach emphasizes an individualized application of MHT, considering not only symptoms caused fluctuating estrogen and progesterone levels; but also factors such as: age, health status, and personal risk factors for cardiovascular disease, metabolic factors, risk for dementia and osteoporosis.

  • Timing Hypothesis: Evidence supports the "timing hypothesis," demonstrating that MHT has a more favorable risk-benefit profile if started near the onset of menopause rather than many years later.

  • Newer Preparations: Multiple studies have shown that newer preprarations of estrogen and progestogens are safer than those preparations studied in the past in the WHI. The new preparations contain estradiol and progesterone, which are chemically identical to those the human body produces.

Risks Cited: Do not apply to newer preparations

Risks

  • Based on older preparations and prescribing practices of MHT, increased risk of breast cancer, cardiovascular disease, dementia, blood clotting and stroke are commonly cited.

  • Multiple studies have shown that our new preparations for MHT do not increase breast cancer risk, indeed decrease cardiovascular and dementia risks when properly used within at least a few years of menopause, and do not increase risk of stoke or blood clots when transdermal preparations are used.

Benefits

  • Symptom Relief

    • MHT remains the most effective treatment for relieving menopausal symptoms such as hot flashes, night sweats, sleep disruption, mood issues and vaginal dryness.

  • Cardiovascular Health

    • Multiple studies have shown a decrease in cardiovascular disease by up to 40% when MHT is initiated soon after menopause.

  • Metabolic Health

    • Multiple studies have shown a decrease in insulin resistance and diabetes risk with MHT.

  • Brain Protection

    • Multiple studies have shown a lower risk of dementia with MHT use when started within 3 to 5 years of menopause.

  • Bone Health

    • HT can help prevent bone loss and reduce the risk of fractures in postmenopausal women.

  • Overall Morality

    • MHT when initiated prior to the age of 60, or within 10 years of the final menstrual period is associated with an approximately 40% lower risk of all cause death.

    • This is largely thought to be due to reductions in cardiovascular disease, the leading cause of death in women

Perspectives for MidLife Women

  • Informed decision making

    • Women should be fully informed of the potential risks and benefits of HT, allowing them to make decisions in collaboration with their healthcare providers.

  • Professional Commitments

    • Healthcare providers should be aware of the newer preparations, new data and modern use of MHT.

  • Non Hormonal Alternatives

    • For those who cannot or prefer not to use MHT, non-hormonal treatments for midlife health and menopausal symptoms should be considered.

    • Even when MHT is employed lifestyle factors impacting health should be reviewed and optimization recommended.

Conclusions

  • Reassessing hormone therapy for women is an ongoing process.

  • Advances in research and a better understanding of individual risk factors and benefits are leading to more personalized and nuanced guidelines.

  • Women considering HT should have thorough discussions with their healthcare providers to determine the best approach based on their specific circumstances.

  • It is important to have a healthcare provider with a multidisciplinary view towards MHT who is educated in the modern approach to MHT.