Treatment of Symptoms of the Menopause: assessing individual Benefits, Risks of Menopausal Therapies

Experts Recommend Assessing Individual Benefits, Risks of Menopausal Therapies

The Endocrine Society today issued a Clinical Practice Guideline (CPG) on identifying women who are candidates for treatment of menopausal symptoms and selecting the best treatment options for each individual.

Endocrine Society – Hormone Science to Health – press release Experts Recommend Assessing Individual Benefits, Risks of Menopausal Therapies

Washington, DC – The Clinical Practice Guideline (CPG), entitled “Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline” was published online and will appear in the November 2015 print issue of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society.

Menopause is the life stage that takes place when a woman’s ovaries dramatically decrease production of the hormones estrogen and progesterone, and her menstrual periods stop. The average age of an American woman experiencing menopause is around 51 years old.

During menopause, many women experience symptoms such as hot flashes, night sweats, sleep disturbances, mood changes, joint pain, recurrent urinary tract infections, and difficult or painful sexual intercourse. These symptoms can start in the years before a woman’s final menstrual period and last for more than a decade.

Women now have a broader range of treatment options for menopausal symptoms than ever before, but many clinicians are reluctant to pursue them. A 2012 Endocrine Society survey found that 72 percent of women currently experiencing menopause symptoms had not received any treatment for them.

Hormone therapy—at one time the most popular treatment for menopausal symptoms— has been under intense scrutiny since 2002, when a large government study called the Women’s Health Initiative (WHI) reported that hormone therapy – specifically the combination of conjugated equine estrogens and medroxyprogesterone acetate (Prempro) – increased the risk for blood clots, stroke, breast cancer and heart attacks in postmenopausal women aged 50 to 79 years at study onset. But additional research conducted in the ensuing years indicated the level of risk depends on the individual woman’s health history, age and other factors. Experts have formed a consensus that the benefits of menopausal hormone therapy exceed the risks for most healthy women seeking relief of menopausal symptoms.

There is no need for a woman to suffer from years of debilitating menopausal symptoms, as a number of therapies, both hormonal and non-hormonal are now available,” said Cynthia A. Stuenkel, MD, the chair of the task force that authored the guideline and an endocrinologist specializing in menopause at the University of California, San Diego. “Every woman should be full partners with her health care providers in choosing whether treatment is right for her and what treatment option best suits her needs. The decision should be based on available evidence regarding the treatment’s safety and effectiveness, as well as her individual risk profile and personal preferences.

In the CPG – see full PDF – the Endocrine Society recommends that women with a uterus who decide to undergo menopausal hormone therapy with estrogen and progestogen be informed about risks and benefits, including the possible increased risk of breast cancer during and after discontinuing treatment. Health care providers should advise all women, including those taking menopausal hormone therapy, to follow guidelines for breast cancer screening.

Other recommendations from the CPG include:

  • Transdermal estrogen therapy by patch, gel or spray is recommended for women who request menopausal hormone therapy and have an increased risk of venous thromboembolism – a disease that includes deep vein thrombosis.
  • Progestogen treatment prevents uterine cancer in women taking estrogen for hot flash relief. For women who have undergone a hysterectomy, it is not necessary.
  • If a woman on menopausal hormone therapy experiences persistent unscheduled vaginal bleeding, she should be evaluated to rule out endometrial cancer or hyperplasia.
  • Medications called selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin or pregabalin are recommended for women who want medication to manage moderate to severe hot flashes, but either prefer not to take hormone therapy or have significant risk factors that make hormone therapy inadvisable.
  • Low-dose vaginal estrogen therapy is recommended to treat women for genitourinary symptoms of menopause, such as burning and irritation of the genitalia, dryness, discomfort or pain with intercourse; and urinary urgency or recurrent infections. This treatment should only be used in women without a history of estrogen-dependent cancers.

The Hormone Health Network, the Endocrine Society’s public education arm, developed an interactive digital resource called the Menopause MapTM for women to explore the stages of menopause and learn about symptoms they may experience. The Menopause MapTM related resources are available. The Hormone Health Network also offers a digital toolkit for health care providers.

Other members of the Endocrine Society task force that developed this CPG include: Susan R. Davis of Monash University in Melbourne, Australia; Anne Gompel of the Université Paris Descartes in Paris, France; Mary Ann Lumsden of the University of Glasgow School of Medicine in Glasgow, Scotland; M. Hassan Murad of the Mayo Clinical in Rochester, MN; JoAnn V. Pinkerton of the University of Virginia in Charlottesville, VA; and Richard J. Santen of the University of Virginia Health System in Charlottesville, VA.This CPG was co-sponsored by the Australasian Menopause Society, British Menopause Society, European Society of Endocrinology and the International Menopause Society.

The Society established the CPG Program to provide endocrinologists and other clinicians with evidence-based recommendations in the diagnosis and treatment of endocrine-related conditions. Each CPG is created by a task force of topic-related experts in the field. Task forces rely on scientific reviews of the literature in the development of CPG recommendations as well as feedback from co-sponsoring societies, members of the Endocrine Society and expert reviewers. The Endocrine Society does not solicit or accept corporate support for its CPGs. All CPGs are supported entirely by Society funds. A list of CPGs can be found here.

Hormone replacement therapy side effects infographic #HRT

The Effects of Hormone Replacement Therapy on the Body.

Hormone replacement therapy can relieve unpleasant symptoms of menopause, but there are some side effects and health risks that should be considered.
Sources and more information

Hormone therapy in transgender adults with provider supervision

Study finds hormone therapy in transgender adults safe

In the most comprehensive review to date addressing the relative safety of hormone therapy for transgender persons, researchers from Boston University School of Medicine (BUSM) have found that hormone therapy in transgender adults is safe.

Boston Medical Center image
Boston Medical Center findings may help reduce the barriers for transgender individuals to receive medical care.

2015 Study Abstract

Some providers report concern for the safety of transgender hormone therapy (HT).

This is a systematic literature review of HT safety for transgender adults.

Current literature suggests HT is safe when followed carefully for certain risks.

  • The greatest health concern for HT in transgender women is venous thromboembolism; increase risk of thrombosis..
  • HT among transgender men appears to cause polycythemia.
  • Both groups experienced elevated fasting glucose.
  • There is no increase in cancer prevalence or mortality due to transgender HT.

Although current data support the safety of transgender HT with physician supervision, larger, long-term studies are needed in transgender medicine.

Sources and more information


HRT: short-term use of hormone replacement therapy linked to ovarian cancer risk increase

HRT increases ovarian cancer risk

HRT menopause treatment ‘doubles the risk of getting ovarian cancer’

HRT at menopause image
Women who undergo hormone replacement therapy (HRT) have a ‘significantly increased’ risk of developing ovarian cancer, according to a major new study.

Researchers from the University of Oxford analysed 52 previous studies involving 21,000 women found that even those who took it for less than five years raised the risk level, although it reduces once they had stopped.

The study, published in the Lancet medical journal, has led to calls for medical guidance on HRT to be updated given the “causal relationship” and the Medical and Healthcare Products Regulatory Authority (MHRA) said it would look at the findings.

The researchers said: ‘The increased risk may well be largely or wholly causal; if it is, women who use hormone therapy for five years from around age 50 have about one extra ovarian cancer per 1,000 users and, if its prognosis is typical, about one extra ovarian cancer death per 1,700 users.

‘The findings that ovarian cancer risk is greatest in current users of hormone therapy, falls after use ceases, and varies by tumour type, strongly suggest a causal relationship – ie: that among otherwise similar women, use of hormone therapy increases the probability of developing the two most common types of ovarian cancer, and hence ovarian cancer as a whole.

‘At present, the WHO, European, and US guidelines about hormone therapy do not mention ovarian cancer, and the UK guidelines – which are due to be revised – state only that risk may be increased with long-term use.

‘The definite risk of ovarian cancer that is observed even with less than five years of use starting at around age 50 is directly relevant to current patterns of hormone therapy use, and hence directly relevant to medical advice, personal choices, and the current efforts to revise UK and worldwide guidelines.’

Hormone replacement therapy (HRT) and the risk of ovarian cancer

MHRA logo
MHRA statement in response to the study in The Lancet on the use of Dr Sarah Branch, deputy director of MHRA’s Vigilance and Risk Management of Medicines (VRMM) Division

” Our advice has always been that the lowest effective dose of HRT should be used for the shortest possible time.

‘We will evaluate the findings of this study and its implications for shorter term use and update product information as necessary.

‘Women on HRT should have regular health check-ups and their need to continue treatment should be reassessed at least annually. Any woman on HRT who has any questions should speak to her doctor who is best placed to advise.”

Sources and more information
  • Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies, the lancet, abstract and full study PDF, 12 February 2015.
  • Short-term use of hormone replacement therapy associated with increased ovarian cancer risk, eurekalert, 12 February 2015.
  • HRT ‘increases ovarian cancer risk‘, BBC News, 13 February 2015

Dr. Susan Love’s Menopause and Hormone Book

Menopause is not a disease that needs to be cured

Dr. Susan Love's Menopause and Hormone Book, by @DrSusanLove, on Flickr
Making Informed Choices

In the first edition of this important bestselling book, praised by Newsday as “the bible for a whole generation of menopausal women”, renowned physician and pioneering women’s health advocate Dr. Susan Love warned about the potential dangers of the long-term prescription of hormone replacement therapy. Her insightful words of caution have been backed up by the stunning results of the recent studies on hormone replacement.

In the revised edition, Dr. Love offers a remarkably clear set of guidelines as to what the studies have shown about the risks regarding:

  • heart disease
  • breast cancer
  • stroke
  • other conditions
  • what effect hormone therapy has on osteoporosis.

She offers definitive expert advice about:

  • whether or not to go on hormone replacement therapy and, if so, for how long
  • as well as how to taper off hormones
  • and she introduces the alternative methods for treating the symptoms of menopause.

Dr. Love stresses that menopause is not a disease that needs to be cured—it is a natural life stage, and every woman ought to choose her own mix of options for coping with symptoms. A questionnaire about your own health history and life preferences helps you develop a program that will best fit your unique needs. With clarity and compassion, she walks you through every option for both the short and the long term, including:

  • lifestyle changes (diet, exercise, and stress management)
  • alternative therapies (including herbs and homeopathic remedies)
  • available medications other than hormones

Book reviews – More about Estrogens – HRTWomen’s Health
Visit Dr. Susan Love website, on Facebook and Twitter

On Flickr®

Hormone Deception

How our environment disrupt our hormones,
How to Protect Yourself and your Family

Hormone Deception by Lindsey Berkson
How our environment disrupt our hormones and how to protect yourself and your family

How Everyday Foods and Products Are Disrupting your Hormones – and How to Protect Yourself and your Family

In Hormone Deception, Lindsey Berkson clearly explains where hormone disruptors come from and how they affect adults, children and the unborn child.
Lindsey also gives easy, practical tips for protecting home and family, such as vacuuming frequently and using water filters.
Lindsey discusses the effects of common synthetic hormones such as birth control pills, hormone replacement therapy and fertility drugs.

Book reviews – Lindsey Berkson Website and Twitter
More about BPAEndocrine DisruptorsPesticidesPhthalates

On Flickr®

No Reason to use Hormone Replacement Therapy to boost Mental Well-Being after Periods Stop

HRT: Estrogen Won’t Make Women Sharper After Menopause

Estrogen Won't Make Women Sharper After Menopause, Study Finds
Low levels of the hormone #estrogen are not to blame for mood swings and poor memory after #menopause, a new study suggests.

Low levels of the hormone estrogen are not to blame for mood swings and poor memory after menopause, a new study suggests.

Based on this finding, the researchers believe there’s no reason to use hormone replacement therapy to boost mental well-being after periods stop.


Variations in the hormonal milieu after menopause may influence neural processes concerned with cognition, cognitive aging, and mood, but findings are inconsistent. In particular, cognitive effects of estradiol may vary with time since menopause, but this prediction has not been assessed directly using serum hormone concentrations. We studied 643 healthy postmenopausal women not using hormone therapy who were recruited into early (-6 y after menopause) and late (10+ y after menopause) groups. Women were administered a comprehensive neuropsychological battery and assessed with the Center for Epidemiologic Studies Depression Scale. They provided serum for free estradiol, estrone, progesterone, free testosterone, and sex hormone binding globulin measurements. Cognitive outcomes were standardized composite measures of verbal episodic memory, executive functions, and global cognition. Covariate-adjusted linear regression analyses were conducted for each hormone separately and after adjustment for other hormone levels. Endogenous sex steroid levels were unassociated with cognitive composites, but sex hormone binding globulin was positively associated with verbal memory. Results for early and late groups did not differ significantly, although progesterone concentrations were significantly positively associated with verbal memory and global cognition in early group women. Hormone concentrations were not significantly related to mood. Results fail to support the hypothesis that temporal proximity to menopause modifies the relation between endogenous serum levels of estradiol and verbal memory, executive functions, or global cognition. Physiological variations in endogenous postmenopausal levels of sex steroid hormones are not substantially related to these aspects of cognition or mood; positive associations for progesterone and sex hormone binding globulin merit additional study.


Estrogen Won’t Make Women Sharper After Menopause, Study Finds, healthday, 25 Nov 2013

Cognition, mood, and physiological concentrations of sex hormones in the early and late postmenopause, PNAS, 23 Oct 2013

Supporting Information, Henderson et al. 10.1073/pnas.1312353110

More information:

High Intake of Sugar-Sweetened Beverages tied to 78% Increase Risk for Endometrial Cancer

Risk of endometrial cancer rises with increase in sugar-sweetened drinks

Researchers found that sugar-sweetened beverage intake was associated with an increased risk – up to 78% higher – type I, but not type II of endometrial cancer.

Endometrial cancer is the fourth most common cancer in women, and eighth most common cause of cancer death among women in the United States.

Studies have shown women’s risk of endometrial cancer increases with higher levels of estrogen in the body – for example, increased estrogen due to diethylstilbestrol DES or taking hormone therapy for the symptoms of menopause.

Researchers found that sugar-sweetened beverage intake was associated with an increased risk – up to 78% higher – type I, but not type II of endometrial cancer. However, its association with endometrial cancer is unclear.

Read Risk of endometrial cancer rises with increase in sugar-sweetened drinks, by Bahar Gholipour, Mother Nature Network

Sources: Sugar-Sweetened Beverage Intake and the Risk of Type I and Type II Endometrial Cancer among Postmenopausal Women, Cancer Epidemiology Biomarkers and Prevention, AACR, 22 Nov 2013 – abstractfull PDF

More DES DiEthylStilbestrol Resources

Brisdelle and Paxil : the Continuing Exploitation Of Menopausal Women

Worst Pills Best Pills, by Dr. Sidney Wolfe

The Continuing Exploitation Of Menopausal Women
Public Citizen HRG, “Protecting your health since 1972”

Medicalizing a normal phase of women’s lives — menopause — for the purpose of selling drugs began decades ago, and it continues on relentlessly. To wit: according to extensive advertising by the drug company Noven, menopausal women will this month have access to “the first and only FDA-approved non-hormonal therapy for moderate to severe hot flashes associated with menopause.”

Continue reading The Continuing Exploitation Of Menopausal Women, by Dr. Sidney Wolfe on DES Info FB Page.

Sources: Worst Pills, Best Pills Newsletter Articles, November 2013.

All our posts about Estrogen – HRT – Menopause

Hormone Replacement Therapy: natural Form of Hormone much better than Synthetic Estrogen

Less Blood Clot Risk Linked to Estradiol Than to Premarin Pills

Less Blood Clot Risk Linked to Estradiol Than to Premarin Pills
Higher risk of incident venous thrombosis and possibly myocardial infarction with the Premarin drug

Women can choose among several types of estrogen pills, which are equally effective at relieving menopausal symptoms. In a head-to-head comparison of two major forms of hormone replacement therapy, a more natural version of estrogen proved less dangerous to the heart than a synthetic one – a patented drug marketed as Premarin.

Read Less Blood Clot Risk Linked to Estradiol Than to Premarin Pills, Science News, 30 Sept 2013.

Read Synthetic Estrogens Pose Greater Clot Risk Than Natural Forms of Hormone, by Alexandra Sifferlin, 1 Oct 2013.

Sources: Lower Risk of Cardiovascular Events in Postmenopausal Women Taking Oral Estradiol Compared With Oral Conjugated Equine Estrogens, JAMA, 30 Sept 2013.

More about estrogens and hormone replacement therapy.

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