Hormone replacement therapy for treating menopausal symptoms: Benefits and risks

Hot flashes, night sweats and sleep disturbances are common symptoms of menopause that can affect health, quality of life and work productivity. A new review published in CMAJ (Canadian Medical Association Journal) https://www.cmaj.ca/lookup/doi/10.1503/cmaj.221438 recommends menopausal hormone therapy, historically known as hormone replacement therapy (HRT), as first-line treatment in people without risk factors.

Menopausal symptoms may occur up to 10 years before the last menstrual period and can last more than 10 years, with negative effects for many people.

"Menopause and perimenopause can be associated with distressing symptoms and reduced quality of life," writes Dr. Iliana Lega, Women's College Hospital and the University of Toronto, Toronto, Ontario, with coauthors. "Menopausal hormone therapy is the first-line treatment for vasomotor symptoms in the absence of contraindications."

The review summarizes the latest evidence for diagnosing and treating menopausal symptoms as well as the risks and benefits of therapies to help clinicians and patients manage the condition.

"Although many treatments exist for menopausal symptoms, fears around the risks of menopausal hormone therapy and lack of knowledge regarding treatment options often impede patients from receiving treatment," write the authors.

Benefits of menopausal hormone therapy include

• reduced hot flashes in as many as 90% of patients with moderate to severe symptoms;
• improved blood lipid levels and a possible reduced risk of diabetes; and
• fewer fragility fractures of the hip, spine and other bones.

What about the risks?

• Although previous evidence has shown an increased risk of breast cancer, the risk is much lower in people aged 50–59 years and in those who start menopausal hormone therapy in the first 10 years of menopause.
• Some studies show an increased risk of ischemic stroke in women older than 60 years who start therapy 10 years after the start of menopause, but the risk is low for those younger than 60.

For people with risk factors or those who do not want to take menopausal hormone therapy, nonhormonal therapies, such as some selective serotonin reuptake inhibitors (SSRIs) and other medications, can help alleviate symptoms.

"Despite early concerns of an increased risk of cardiovascular events with menopausal hormone therapy after the Women's Health Initiative trial, increasing evidence shows a possible reduction in coronary artery disease with menopausal hormone therapy among younger menopausal patients, specifically those who start menopausal hormone therapy before age 60 years or within 10 years of menopause," write the authors.

They emphasize that it's important for clinicians to ask about symptoms before and during menopause and to discuss treatments with patients based on their personal preferences and potential risk factors.