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NAMS 2017 position statement updates guidelines for hormone therapy use

A new position statement on the use of hormone therapy (HT) for menopausal and postmenopausal women from The North American Menopause Society (NAMS) has been published online today in the Society's journal, Menopause. "The use of hormone therapy continues to be one of the most controversial and debated topics," says Dr. JoAnn V. Pinkerton, NAMS executive director. "The goal of this updated version of the Society's position statement is to provide excellent, evidence-based, current clinical recommendations to menopause practitioners for the improvement of care for women depending on them to help relieve menopause symptoms." The statement also reviews the effects of HT on various health conditions, such as cardiovascular disease and breast cancer, at different stages of a woman's life.

What's new in the 2017 position statement? The statement expands on and solidifies NAMS's previous position on several critical areas of confusion regarding HT:

  • The risks of HT differ for different women, depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is needed. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation for the benefits and risks of HT continuation.
  • For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio appears favorable for treatment of bothersome hot flashes and for those at elevated risk of bone loss or fracture. Longer duration may be more favorable for estrogen-alone therapy than for estrogen-progestogen therapy, based on the Women's Health Initiative randomized, controlled trials.
  • For women who initiate HT more than 10 or 20 years from menopause onset or when aged 60 years or older, the benefit-risk ratio appears less favorable than for younger women because of greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia.
  • Hormone therapy does not need to be routinely discontinued in women aged older than 60 or 65 years and can be considered for continuation beyond age 65 years for persistent hot flashes, quality-of-life issues, or prevention of osteoporosis after appropriate evaluation and counseling of benefits and risks.
  • Vaginal estrogen (and systemic if required) or other nonestrogen therapies may be used at any age for prevention or treatment of the genitourinary syndrome of menopause.

"NAMS discovered through its review of the literature that the previous position that hormone therapy should be prescribed only for the 'lowest dose for the shortest period of time' may be inadequate or even harmful for some women," says Dr. Pinkerton. "NAMS has clarified this position to the more fitting concept of the 'appropriate dose, duration, regimen, and route of administration' that provides the most benefit with the minimal amount of risk. In addition, women older than 65 years old will be relieved to know that they don't have to stop using hormone therapy for their bothersome hot flashes just because of their age. The data simply do not support it, but individualized evaluation and discussion is recommended."

Abstract

The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone TherapyPosition Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees.Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian MenopauseSociety, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d'études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.

Reference

The 2017 hormone therapy position statement of The North American Menopause Society. [No authors listed] Menopause. 2017 Jun 22. doi: 10.1097/GME.0000000000000921. [Epub ahead of print]

http://www.menopause.org/docs/default-source/2017/nams-2017-hormone-therapy-position-statement.pdf

Content updated 26 June 2017

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