Estrogen and Progestogen Use in Postmenopausal Women

2010 Position Statement of the North American Menopause Society

Posted: 04/28/2010; Menopause. 2010;17(2):242-255. © 2010

Objective: To update for both clinicians and the lay public the evidence-based position statement published by The North American Menopause Society (NAMS) in July 2008 regarding its recommendations for menopausal hormone therapy (HT) for postmenopausal women, with consideration for the therapeutic benefit-risk ratio at various times through menopause and beyond.

Methods: An Advisory Panel of clinicians and researchers expert in the field of women's health was enlisted to review the July 2008 NAMS position statement, evaluate new evidence through an evidence-based analysis, and reach consensus on recommendations. The Panel' s recommendations were reviewed and approved by the NAMS Board of Trustees as an official NAMS position statement. Also participating in the review process were other interested organizations who then endorsed the document.

Results: Current evidence supports a consensus regarding the role of HT in postmenopausal women, when potential therapeutic benefits and risks around the time of menopause are considered. This paper lists all these areas along with explanatory comments. Areas that vary from the 2008 position statement are noted. A suggested reading list of key references published since the last statement is also provided.

Conclusions: Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal women; or both.
The benefit-risk ratio for menopausal HT is favorable for women who initiate HT close to menopause but decreases in older women and with time since menopause in previously untreated women.

Introduction

The North American Menopause Society (NAMS), a nonprofit scientific organization, published position statements on the role of menopausal hormone therapy (HT) in October 2002 (Menopause 2003;10:6–12), September 2003 (Menopause 2003;10:497–506), October 2004 (Menopause 2004; 11:589–600), March 2007 (Menopause 2007;14:168–182), and July 2008 (Menopause 2008;15:584–603). The goal of these position statements was to clarify the benefit-risk ratio of HT-as either estrogen therapy (ET) or combined estrogen-progestogen therapy (EPT)-for both treatment of menopause-related symptoms and disease prevention at various times through menopause and beyond.

Because of the rapidly evolving data influencing the interaction of the benefit-risk ratio of HT and clinical management of aging women, the NAMS Board of Trustees recognized the need to update its position statement. NAMS convened a sixth Advisory Panel to provide recommendations and also place therapeutic benefits and risks into perspective for both clinicians and the lay public. The opportunity was also taken to work in collaboration with The Endocrine Society in their development of a detailed Scientific Statement regarding the use of HT after menopause. The Panel's recommendations were reviewed and approved by the 2009–2010 NAMS Board of Trustees.

The Society's position statements provide expert analysis of the totality of the data, including the most recent scientific evidence, in an attempt to assist healthcare providers in their practices and women in their decision making. These statements do not represent codified practice standards as defined by regulating bodies and insurance agencies.

Summary

The potential absolute risks published thus far for use of HT are low, particularly for the WHI ET trial, which provided evidence of considerable safety for 0.625 mg/day of oral CE. The risks in the WHI EPT trial were rare by the criteria of the Council for International Organizations of Medical Sciences, except for stroke, which was above the rare category. For women younger than age 50 or those at low risk of CHD, stroke, osteoporosis, breast cancer, or colon cancer, the absolute risk or benefit from ET or EPT is likely to be even smaller than that demonstrated in the WHI, although the relative risk at different ages may be similar. There is a growing body of evidence that each type of estrogen and progestogen, route of administration, and timing of therapy has distinct beneficial and adverse effects. Further research remains essential.