Menopause is defined by the absence of menstruation for 12 months. This means you technically will not receive a diagnosis until it is over. The North American Menopause Society (NAMS) is helping physicians learn more about this transition to teach menstruating people that they don't have to suffer through and more importantly, they don't have to fear treatment.
Females are born with a certain number of eggs and this number decreases over a lifetime. Menopause begins when estrogen and other hormone levels decrease over time as the volume of eggs. There is a time when hormone levels are fluctuating and lead to vasomotor symptoms including hot flashes, sleep disturbances, vaginal/skin dryness and mood changes. Moreover, longterm changes include accelerated bone loss and increased risk of coronary artery disease. These patients find it hard to function in their home and at work. The fear of sudden onset of temperature changes prevent women from taking on leadership roles. Similar to when women undergo pregnancy and birth, they often turn to their mothers and other women in their lives for advice. While this is often reliable and sound advice, we must also turn to the science. There are safe hormonal and nonhormonal treatments to help patients exist in this world during this normal and expected transition.
NAMS came out with updated guidelines in 2022. These guidelines are based on science and serve to clarify any previous fears from misinterpretation of research.
The North American Menopause Society Updated guidelines on Hormone Replacement Therapy 2022
The last position statement was in 2017. The North American Menopause Society is an independent organization that offers guidance on evidence-based treatment of perimenopausal or menopausal women with hormonal and non-hormonal forms of treatment. For historical context, many women used HRT in the 1980s. It wasn't until the results of the Women's Health Initiative (WHI) study came out that the medical community began to doubt the safety of hormone treatment. The WHI study that focused on strategies for preventing heart disease, breast and colorectal cancer, and osteoporosis in postmenopausal women. The original study had 3 parts - a clinical trial, an observational study, and a community prevention study—and completed data collection in 2005. The clinical study enrolled more than 68,000 women between the ages of 50-79. All HRT was oral therapy and no transdermal HRT was studied.(https://www.nhlbi.nih.gov/science/womens-health-initiative-whi))
Women who had a uterus - Combined progestin and estrogen treatment
Women who no longer had a uterus - Oral estrogen alone
WHI also collected data to study vitamin D/calcium intake as well as low-fat whole food diet and lifestyle choices including exercise and smoking. The Women’s Health Initiative (WHI) is the largest, randomized, controlled trial (RCT) of hormone therapy in women aged 50 to 79 years, and its findings were therefore given prominent consideration. However, it is important to note that the WHI employed just one route of administration (oral), one formulation of estrogen (conjugated equine estrogens [CEE] 0.625 mg), and only one progestogen (medroxyprogesterone acetate [MPA] 2.5 mg), with limited enrollment of women with bothersome vasomotor symptoms (VMS; hot flashes, night sweats) who were aged younger than 60 years or who were fewer than 10 years from menopause onset—the group of women for whom hormone therapy is currently primarily indicated. This is because this study was not meant to evaluate vasomotor symptoms. It was designed to evaluate the effect of HRT on coronary artery disease, cancers and osteoporosis. This NAMS position statement includes the WHI study as well as other well-designed randomized control trials as well as cross-sectional studies.
Contraindications for oral and transdermal hormone therapy include unexplained vaginal bleeding; liver disease; prior estrogensensitive cancer (including breast cancer); prior coronary heart disease (CHD), stroke, MI, or VTE; or personal history or inherited high risk of thromboembolic disease.
Potential risks of hormone therapy for women aged younger than 60 years include the rare risk of breast cancer with EPT; endometrial hyperplasia and endometrial cancer with inadequately opposed estrogen; VTE; and gallbladder disease
Overall, the increased absolute risks associated with estrogen plus progestrone and estrogen alone are rare (<10/10,000/y) and include increased risk for VTE and gallbladder disease.
Estrogen plus progesterone carries a rare increased risk for stroke and breast cancer, and if estrogen is not balanced with progesterone, an increased risk of endometrial hyperplasia and endometrial cancer. (Level I) • The absolute risks are reduced for all-cause mortality, fracture, diabetes mellitus for estrogen plus progesterone or estrogen alone, and breast cancer in estrogen alone in women aged younger than 60 years. (Level I)
• Level I: Based on good and consistent scientific evidence.
• Level II: Based on limited or inconsistent scientific evidence.
• Level III: Based primarily on consensus and expert opinion.
What is HRT approved for?
Vasomotor symptoms due to "natural" or hypoestrogenism after surgical removal of ovaries or primary ovarian failure
Prevention of bone loss (not treatment of osteoporosis)
What is bioidentical hormones?
All hormone preparations are bio-identical. There are government-approved (verified by the FDA) and compounded forms of bio-identical hormones but all are synthetic.
Do I need to have my hormones checked?
Using serum or urinary testing is unnecessary to guide treatment.