Navigating Menopause: A Comprehensive Guide to Hormone Replacement Therapy – ARC Summit

Thank you, Dr. Abdallah, for inviting me to this conference. I’m excited to present on hormonal therapy for menopause and the transition period. Today, I will discuss the management of menopause, highlighting the benefits, risks, and different administration methods of hormonal therapy (HRT), particularly focusing on its impact on the cardiovascular system.

In the Women’s Health Initiative (WHI) study, the combined conjugated equine estrogen (CE) and medroxyprogesterone acetate (MPA) arm was halted due to a reported increase in coronary heart disease by 24%. However, subsequent analyses and follow-up studies, such as the Danish Osteoporosis Prevention Study and the ELITE trial, introduced the “timing hypothesis.” This hypothesis suggests that HRT, when started within 10 years of menopause, significantly reduces cardiovascular risks rather than increases them.

These findings were supported by various studies, including those analyzing national death registries in Finland and multiple meta-analyses. They consistently showed that starting HRT near menopause transition could lower or neutralize the risk of coronary heart disease. Additionally, although the WHI trials initially suggested an increase in stroke and venous thromboembolism (VTE) risks, later studies with oral estradiol and transdermal applications painted a more complex picture, indicating a potentially lower risk depending on the method of hormone delivery.

Regarding VTE, while the WHI found a twofold increase in risk with certain HRT applications, other forms such as transdermal estradiol did not show the same level of risk, and some studies even reported a reduced risk of blood clots.

It is crucial to personalize HRT, considering each woman’s unique health profile and symptomatology. The choice of hormones, particularly the type of estrogen and progesterone, plays a critical role in the safety and efficacy of treatment. For instance, natural progesterones like micronized progesterone or dydrogesterone have shown better profiles in terms of metabolic effects and breast tissue response compared to synthetic options like MPA.

In conclusion, while HRT was viewed cautiously following the initial WHI results, ongoing research and better understanding of hormone interactions have led to more nuanced approaches. These approaches emphasize the importance of personalized treatment plans, the timing of hormone initiation, and the selection of hormone types to maximize benefits and minimize risks. As we move forward, it’s vital to continue educating both providers and patients about these developments to improve the quality of menopause management effectively.