Meeting NewsPerspective

‘One size does not fit all’ when it comes to postmenopausal hormone therapy

BOSTON Hormone therapy remains an important option for improving quality of life for recently menopausal women with bothersome symptoms, but the regimen should not be used as a method for preventing cardiovascular disease, according to a presenter at the Cardiometabolic Health Congress.

When considering HT, health care providers should turn to risk stratification and shared decision-making with patients, JoAnn E. Manson, MD, professor of medicine at Harvard Medical School and chief of the division of preventive medicine within the department of medicine at Brigham and Women’s Hospital in Boston, said during her presentation.

“The prescribing of menopausal hormone therapy … is certainly a situation where one size does not fit all,” Manson said. “Clinicians looking for something that’s good for all patients or bad for all patients [will find] hormone replacement therapy does not fit that mold.”

Manson reviewed evidence from the pivotal Women’s Health Initiative (WHI) trials, other randomized trials, and observational studies, and offered caveats to some of the data.

Observational studies in the 1980s and 1990s were “so influential,” Manson said, in leading to the belief that HT protected against CVD, but lifestyle and socioeconomic factors can lead to some residual confounding of the results.

Data from the WHI studies published in 2002 suggested that HT with estrogen plus progestin increased the risk for CV complications, stroke, venous thrombosis, pulmonary thromboembolism and breast cancer, and that estrogen alone increased the risk for stroke, but not coronary heart disease, pulmonary embolism or cancers.

The findings were clearer when data were analyzed by age group, Manson said. The mean age of WHI participants was 63 years vs. 52 years in observational studies. Consequently, there was a difference of more than a decade in when most of the participants began HT in relation to menopause onset. Data showed that absolute risks for adverse events such as CVD, breast cancer, stroke and colorectal cancer were much lower among women in their fifties who received HT vs. those in their sixties and seventies, according to Manson. And women in early menopause did not have an increased risk for heart disease on HT.

“There was collateral damage [from these trials],” Manson said. “Younger women who were in early menopause and had very distressing symptoms, such as hot flashes, night sweats, disrupted sleep and impaired quality of life, were also stopping hormone therapy, and their clinicians were telling them to stop. Women newly entering menopause were no longer being evaluated to see if they would be candidates for the hormone therapy.”

With more than 75% of peri- or post-menopausal women experiencing hot flashes and/or night sweats, and about 20% of women having moderate to severe symptoms, “HT continues to have an important clinical role in the management of these symptoms,” Manson said. “The current evidence, however, does not support the use of hormone therapy for the express purpose of trying to prevent cardiovascular disease.”

Other menopause symptom treatment options include transdermal hormone therapy, which avoids hepatic first-pass metabolism, and minimally stimulates hepatic clotting protein production or triglyceride synthesis, according to Manson.

Manson noted that both transdermal and low-dose oral HT options have less effect on blood pressure, C-reactive protein, clotting factors and triglyceride levels than higher-dose oral HT.

Non-hormonal therapies for menopausal symptoms, such as paroxetine, venlafaxine, escitalopram and gabapentin, are “good options for women to have,” according to Manson, but she added that these are typically not as effective as HT (40% to 50% vs. 70% to 80% reduction in hot flashes in some instances).

Manson recommended that health care providers consider patient characteristics, such as age, time since menopause onset, and underlying CVD risk score when discussing therapy options. The app MenoPro NAMS, sponsored by the North American Menopause Society, can be helpful for risk stratification and encourages shared decision-making with the patient, she noted.

“This app tells you about the side effects and risks of hormone therapy … and can help calculate CVD risk scores … and provides guidance on the best therapy,” she said.   - by Janel Miller

For more information:

The MenoPro NAMS app is available at www.menopause.org/for-women/-i-menopro-i-mobile-app.

Reference:

Manson JE. Updates on the role of postmenopausal hormone replacement therapy. Presented at: Cardiometabolic Health Congress; Oct. 24-27, 2018; Boston.

Disclosure: Manson reports no relevant financial disclosures.

BOSTON Hormone therapy remains an important option for improving quality of life for recently menopausal women with bothersome symptoms, but the regimen should not be used as a method for preventing cardiovascular disease, according to a presenter at the Cardiometabolic Health Congress.

When considering HT, health care providers should turn to risk stratification and shared decision-making with patients, JoAnn E. Manson, MD, professor of medicine at Harvard Medical School and chief of the division of preventive medicine within the department of medicine at Brigham and Women’s Hospital in Boston, said during her presentation.

“The prescribing of menopausal hormone therapy … is certainly a situation where one size does not fit all,” Manson said. “Clinicians looking for something that’s good for all patients or bad for all patients [will find] hormone replacement therapy does not fit that mold.”

Manson reviewed evidence from the pivotal Women’s Health Initiative (WHI) trials, other randomized trials, and observational studies, and offered caveats to some of the data.

Observational studies in the 1980s and 1990s were “so influential,” Manson said, in leading to the belief that HT protected against CVD, but lifestyle and socioeconomic factors can lead to some residual confounding of the results.

Data from the WHI studies published in 2002 suggested that HT with estrogen plus progestin increased the risk for CV complications, stroke, venous thrombosis, pulmonary thromboembolism and breast cancer, and that estrogen alone increased the risk for stroke, but not coronary heart disease, pulmonary embolism or cancers.

The findings were clearer when data were analyzed by age group, Manson said. The mean age of WHI participants was 63 years vs. 52 years in observational studies. Consequently, there was a difference of more than a decade in when most of the participants began HT in relation to menopause onset. Data showed that absolute risks for adverse events such as CVD, breast cancer, stroke and colorectal cancer were much lower among women in their fifties who received HT vs. those in their sixties and seventies, according to Manson. And women in early menopause did not have an increased risk for heart disease on HT.

“There was collateral damage [from these trials],” Manson said. “Younger women who were in early menopause and had very distressing symptoms, such as hot flashes, night sweats, disrupted sleep and impaired quality of life, were also stopping hormone therapy, and their clinicians were telling them to stop. Women newly entering menopause were no longer being evaluated to see if they would be candidates for the hormone therapy.”

With more than 75% of peri- or post-menopausal women experiencing hot flashes and/or night sweats, and about 20% of women having moderate to severe symptoms, “HT continues to have an important clinical role in the management of these symptoms,” Manson said. “The current evidence, however, does not support the use of hormone therapy for the express purpose of trying to prevent cardiovascular disease.”

Other menopause symptom treatment options include transdermal hormone therapy, which avoids hepatic first-pass metabolism, and minimally stimulates hepatic clotting protein production or triglyceride synthesis, according to Manson.

Manson noted that both transdermal and low-dose oral HT options have less effect on blood pressure, C-reactive protein, clotting factors and triglyceride levels than higher-dose oral HT.

Non-hormonal therapies for menopausal symptoms, such as paroxetine, venlafaxine, escitalopram and gabapentin, are “good options for women to have,” according to Manson, but she added that these are typically not as effective as HT (40% to 50% vs. 70% to 80% reduction in hot flashes in some instances).

Manson recommended that health care providers consider patient characteristics, such as age, time since menopause onset, and underlying CVD risk score when discussing therapy options. The app MenoPro NAMS, sponsored by the North American Menopause Society, can be helpful for risk stratification and encourages shared decision-making with the patient, she noted.

“This app tells you about the side effects and risks of hormone therapy … and can help calculate CVD risk scores … and provides guidance on the best therapy,” she said.   - by Janel Miller

For more information:

The MenoPro NAMS app is available at www.menopause.org/for-women/-i-menopro-i-mobile-app.

Reference:

Manson JE. Updates on the role of postmenopausal hormone replacement therapy. Presented at: Cardiometabolic Health Congress; Oct. 24-27, 2018; Boston.

Disclosure: Manson reports no relevant financial disclosures.

    Perspective
    Lisa N. Hawes MD

    Lisa N. Hawes MD

    I am thrilled to see that someone is finally talking about fecal incontinence. Not only is this a silent problem, it severely curbs the social lives of millions of people in the United States. No one wants to admit they are incontinent of urine but being incontinent of stool is an even greater social stigma.

    It is unfortunate that so few physicians ask their patients about this problem. In the study by Brown et al, geriatricians seemed most in tune with this condition. My concern is that few residents and fellows are asking these critical questions. This is a missed opportunity with an aging population if our younger physicians are not being properly trained to inquire about these issues.

    Part of the reason for not addressing this question is the lack of physician education about possible treatment options for fecal incontinence. Sometimes simple diet changes can improve this problem. Other patients will likely benefit from InterStim, an FDA-approved implantable neuromodulator that not only improves fecal but also urinary incontinence. Medtronic, the company which makes the device, has lots of literature available for medical providers to educate them and their patients about the issue. Should a primary care physician uncover this problem in patients, I recommend a referral to a gastroenterologist for initial evaluation.

    Fecal incontinence can be a life-changing disease that warrants a primary care physician’s full attention. Primary care physicians with patients who complain of fecal incontinence — things like diarrhea, constipation, hemorrhoids, muscle weakness in the anus, pelvic or rectum areas should ask their patients about loss of stool control and if warranted based on severity, ask the patient to consider further evaluation. Adding this question to the intake questionnaire for well visits is another way to open the door for this delicate conversation. Kudos to the authors of this article who have highlighted this oft-ignored concern.

    • Lisa N. Hawes MD, MD
    • Urologist, Chesapeake Urology, Maryland

    Disclosures: Hawes reports no relevant financial disclosures.

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