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Gynecology

Hormonal therapy during menopause

10 February 2025

Have you ever wondered if you should take hormone therapy during menopause (HRT)? Is hormone therapy an “elixir of youth”?

  • No, hormones are not a “natural” treatment
  • Yes, but it’s scary because hormones can cause cancer
  • I have friends who take hormones and they feel great, but I’m afraid that in the long term they will have side effects

Do you see yourself reflected in any thoughts?

Hormone therapy for menopause has advantages and disadvantages. We will discuss it in detail:

The idea of administering a combination of estrogen and progesterone to improve the symptoms of a drop in these hormones began in the 1940s, and although it seems to make sense at first, the controversy between benefits and risks makes the decision to start this treatment very difficult for both patients and doctors.

How did we get here? Reasons for the controversy

Women’s Health Initiative. WHI

Until menopause, due to the protective effect of estrogen in women, they have a lower risk of cardiovascular disease than men, but with the arrival of menopause the risk of heart attack, cardiovascular disease, as well as bone fractures and cognitive deterioration increases. With the idea of extending women's life expectancy, as well as improving other symptoms associated with the lack of estrogen (such as hot flashes, insomnia, irritability, fatigue, etc.), in the 1990s it was common practice to recommend estrogen or estrogen and progesterone supplements to women, and so Internal Medicine and Gynecology.

In 1993, a prospective study was initiated in 160,000 postmenopausal women aimed at comparing the effectiveness of THM, especially aimed at preventing cardiovascular disease. This study was the WHI.

In 2003, the study was suspended because, contrary to expectations, the treatment not only did not reduce the risk of heart attack, but it increased the risk of cerebrovascular disease and thrombosis. In addition, in the Estrogens combined with progesterone arm, an increased risk of breast cancer was observed. Not only that, but THM was also associated with an increase in dementia.

This fell like a bombshell on the scientific community that spread to general journals, causing real panic among patients. From then on, the production and consumption of hormones decreased drastically, as well as new studies on the subject. To date, this remains the study with the most cases and the longest follow-up on the effect of THM.

And now…. what do we do?

Women around the world are reaching menopause and the decision of whether or not to start HRT remains a source of conflict and fear, causing a large number of prospective patients to refuse treatment due to the disclosure of all the negative effects of the treatment. Hormonal phobia. However, as life expectancy increases and quality of life improves at older ages, menopausal women continue to suffer interference in our daily lives due to hot flashes, insomnia, anxiety, depression, as well as an increased risk of dementia higher than men.


In 2022, a consensus on Hormone Therapy was published by the American Menopause Society. Let's look at the key points4:

Hormone therapy remains the most effective treatment for:

  • Vasomotor symptoms (VMS)
  • Genitourinary syndrome of menopause
  • It has been shown to prevent bone loss and fractures.

The risks of hormone therapy vary depending on the type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used.

Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reassessment of the benefits and risks of continuing therapy.

In women under 60 years of age or within 10 years of menopause and without contraindications, the benefit-risk ratio is favorable for the treatment of bothersome vasomotor symptoms and the prevention of bone loss.

In women who start hormone therapy more than 10 years after the onset of menopause or who are over 60 years of age, the benefit-risk ratio appears less favorable due to higher absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer-term therapies should be reserved for documented indications, such as persistent vasomotor symptoms, with shared decision-making and periodic reassessment.

For bothersome symptoms of the genitourinary syndrome of menopause that do not improve with over-the-counter therapies in women with a contraindication to THM, vaginal therapy with low-dose estrogen or other therapeutic options is recommended (for example, vaginal dehydroepiandrosterone or oral ospemifene). We could also include vaginal laser treatment.

Bibliography:

  1. Barratt A, Wyer PC, Hatala R, McGinn T, Dans AL, Keitz S, Moyer V, For GG; Evidence-Based Medicine Teaching Tips Working Group. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. CMAJ. 2004 Aug 17;171(4):353-8. doi: 10.1503/cmaj.1021197. PMID: 15313996; PMCID: PMC509050.
  2. Furness S, Roberts H, Marjoribanks J, Lethaby A. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database Syst Rev. 2012 Aug 15;2012(8):CD000402. doi: 10.1002/14651858.CD000402.pub4. PMID: 22895916; PMCID: PMC7039145.
  3. Sjögren LL, Mørch LS, Løkkegaard E. Hormone replacement therapy and the risk of endometrial cancer: A systematic review. Maturitas. 2016 Sep;91:25-35. doi: 10.1016/j.maturitas.2016.05.013. Epub 2016 Jun 1. PMID: 27451318.
  4. “The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022 Jul 1;29(7):767-794. doi: 10.1097/GME.0000000000002028. PMID: 35797481.
  5. Thornton MJ. Estrogens and aging skin. Dermatoendocrinol. 2013 Apr 1;5(2):264-70. doi: 10.4161/derm.23872. PMID: 24194966; PMCID: PMC3772914.
  6. Woods NF, Utian W. Quality of life, menopause, and hormone therapy: an update and recommendations for future research. Menopause. 2018 Jul;25(7):713-720. doi: 10.1097/GME.0000000000001114. PMID: 29933353.
  7. Qaseem A, Forciea MA, McLean RM, Denberg TD; Clinical Guidelines Committee of the American College of Physicians; Barry MJ, Cooke M, Fitterman N, Harris RP, Humphrey LL, Kansagara D, McLean RM, Mir TP, Schünemann HJ. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians. Ann Intern Med. 2017 Jun 6;166(11):818-839. doi: 10.7326/M15-1361. Epub 2017 May 9. Erratum in: Ann Intern Med. 2017 Sep 19;167(6):448. doi: 10.7326/L17-0463. PMID: 28492856.
  8. Watt FE. Hand osteoarthritis, menopause and menopausal hormone therapy. Maturitas. 2016 Jan;83:13-8. doi: 10.1016/j.maturitas.2015.09.007. Epub 2015 Oct 1. PMID: 26471929.
  9. Greendale GA, Sternfeld B, Huang M, Han W, Karvonen-Gutierrez C, Ruppert K, Cauley JA, Finkelstein JS, Jiang SF, Karlamangla AS. Changes in body composition and weight during the menopause transition. JCI Insight. 2019 Mar 7;4(5):e124865. doi: 10.1172/jci.insight.124865. PMID: 30843880; PMCID: PMC6483504.
  10. Resnick SM, Henderson VW. Hormone therapy and risk of Alzheimer disease: a critical time. JAMA. 2002 Nov 6;288(17):2170-2. doi: 10.1001/jama.288.17.2170. PMID: 12413378.
  11. Maki PM, Kornstein SG, Joffe H, Bromberger JT, Freeman EW, Athappilly G, Bobo WV, Rubin LH, Koleva HK, Cohen LS, Soares CN; Board of Trustees for The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018 Oct;25(10):1069-1085. doi: 10.1097/GME.0000000000001174. PMID: 30179986.
  12. Singletary SE. Rating the risk factors for breast cancer. Ann Surg. 2003 Apr;237(4):474-82. doi: 10.1097/01.SLA.0000059969.64262.87. PMID: 12677142; PMCID: PMC1514477.
  13. Fournier A, Mesrine S, Dossus L, Boutron-Ruault MC, Clavel-Chapelon F, Chabbert-Buffet N. Risk of breast cancer after stopping menopausal hormone therapy in the E3N cohort. Breast Cancer Res Treat. 2014 Jun;145(2):535-43. doi: 10.1007/s10549-014-2934-6. Epub 2014 Apr 30. Erratum in: Breast Cancer Res Treat. 2014 Aug;147(1):225. PMID: 24781971; PMCID: PMC5924370.