The latest recommendations from the Menopause Society (formerly known as the North American Menopause Society) have sparked a significant shift in how hormone therapy (HT) is viewed, particularly concerning the duration of use. Unlike previous guidelines that suggested a 5-7-year limit based on the type of HT (estrogen and progestin versus estrogen alone), the 2023 position statement emphasizes that there’s no longer a predetermined time to stop hormone therapy. Instead, the decision should be guided by an ongoing evaluation of the benefits relative to the risks for each individual.

The Menopause Society outlines several benefits of HT, including effective management of hot flashes, relief from urinary and vaginal symptoms, and prevention of osteoporosis. HT is also the standard of care in women who experience premature menopause. However, the data surrounding the use of HT for preventing cardiovascular disease and cognitive decline remains inconclusive. The Menopause Society (along with the British Menopause Socity and The Royal College of Obstetricians and Gynecologists) do not recommend HT solely for the prevention of cardiovascular diseae and dementia.  

This brings up a common question: What should a woman do if she starts HT for hot flashes within the first decade of menopause and wishes to continue HT beyond this time? The use of HT remains a complex issue, with research evolving since the major studies of the 1990s, such as the Women’s Health Initiative (WHI) and the Heart and Estrogen/Progestin Replacement Study (HERS).

A recent study published in the October 2023 issue of Menopause, “Benefits for cardiovascular system, bone density, and quality of life of a long-term hormone therapy in hysterectomized women: a 20-year follow-up study”.  This work offers valuable insights into the long-term use of HT in women who initiated treatment early in menopausal life. 

Study Overview

This study, conducted by Dr. Maria Isabel Lorite and her team in Granada, Spain, aimed to examine the effects of two decades of transdermal estradiol HT on women post-hysterectomy, focusing on menopausal symptoms, cardiovascular health, bone density, and overall quality of life.

This was a forward-looking observational study that followed 259 women who had undergone a hysterectomy, the majority for non-cancerous reasons. They were started on a daily dose of 0.05 mg of transdermal estradiol, which was halved when they reached 60 years old. The study spanned 20 years, with 56 women completing the full follow-up.

Key Findings

  • Quality of Life: Women who remained in the study reported a significant reduction in menopausal symptoms, as measured by the Kupperman Index, after 20 years of HT.
  • Cardiovascular Health: Despite a slight increase in BMI, there were favorable changes in lipid profiles, including a reduction in LDL and total cholesterol levels, even after the dosage was reduced.
  • Bone Health: Bone mineral density improved significantly, and there were no fractures reported in the study cohort.
  • Breast Cancer Risk: The study found no significant increase in breast cancer risk among the participants, with the incidence aligning with what would be expected in the general population.

Author’s Conclusions

The authors of the study suggest that long-term transdermal estradiol HT provides benefits for cardiovascular health and bone density, particularly when started close to menopause and continued past age 60 in women who have had a hysterectomy.

A Critical Look

While the study offers valuable insights, it’s important to recognize its limitations. The small sample size and the fact that a significant number of participants discontinued HT (many due to misinformation) raise questions about the generalizability of the findings. Furthermore, the study focused on a specific group of women—those who had undergone a hysterectomy and were on estrogen-only HT—limiting its applicability to the broader population of women considering HT.

The study’s conclusion that long-term HT can serve as a primary preventive therapy for cardiovascular and bone diseases in postmenopausal women over 60 years old is somewhat overstated given these limitations. Larger, randomized controlled trials are necessary to validate these findings and provide clearer guidance.

Final Thoughts

Despite its limitations, this study contributes valuable data to the ongoing conversation about long-term hormone therapy. Its findings align with the Menopause Society 2023 Position Statement, suggesting that for some women, particularly those who have had a hysterectomy, continuing HT for an extended period may be beneficial if the benefits outweigh the risks.

For women navigating the complexities of hormone therapy, expert guidance is essential. Dr. Carla DiGirolamo, a pioneer in women’s performance endocrinology, specializes in helping active and high-performing women optimize their health from puberty through menopause. Her expertise ensures that women receive personalized, informed advice on whether and how long to continue HT based on their unique health profiles and goals. Schedule a consultation with Dr. DiGirolamo today to take the next step in managing your health and performance.

Reference

https://www.athleticaging.blog/p/hormones-for-the-long-haul-the-jury