What are the current guidelines for taking hormones?

So what are the current (2020) guidelines for taking hormones after menopause? First of all, to make sure everyone is on the same page, the term menopause refers to that point in time when a woman no longer is fertile and the ovaries have essentially quit producing hormones. If a woman is around 50 years old and goes 12 months without a period – she can be pretty sure she has reached menopause.  In addition, if a woman underwent surgical removal of her ovaries, she also would automatically have become menopausal.

Taking hormones after menopause is typically referred to as taking hormone replacement therapy, or HRT.  This involves estrogen replacement and, in many cases, progesterone replacement..  Whether to take one or both hormones depends on whether or not a woman has her uterus. For women who still have a uterus, estrogen plus some form of progesterone is recommended because estrogen alone may increase the risk of uterine cancer and it has been shown that taking a progesterone-like drug eliminates this risk.  For women who have had a hysterectomy, the current guidelines recommend that women take only estrogen if they choose to take HRT.

This gets us to the main question:  how should doctors advise menopausal women about hormones?  They base their recommendations on guidelines that are published by various professional groups.  These guidelines are developed by panels of experts who review the studies evaluating which treatments have come up with the best results.   Guidelines for taking HRT are published by such organizations as the American Medical Association and the American College of Obstetricians and Gynecologists.  In addition, there is a governmental body called the United States Preventative Services Task Force (USPSTF) that independently looks at all this data and formulates guidelines.  Because new studies come out all the time, these organizations periodically update their guidelines – particularly if new research shows that an alternate treatment is “proven” to give better results.

HRT guidelines have changed over the years. Back in the 1980s and 1990s (when I started my practice in internal medicine) the guidelines pretty much encouraged most women to take hormones after menopause and continue them, in many cases, indefinitely. This was based on numerous studies that showed that taking HRT led to more benefits than risks.

Now the guidelines are very different. This is because in 2002 a huge study called the Women’s Health Initiative (WHI) was published that concluded that women taking hormones had higher risks of heart attacks, strokes, breast cancer, blood clots and dementia than women who did not take hormones. This led to new guidelines that advised that women only take the lowest doses of hormones for the shortest periods of time, and only if they were having severe hot flashes.  So instead of encouraging women to take HRT, they are being discouraged from taking it.

It seems strange that the guidelines for HRT changed so dramatically over the last two decades.  Does this imply that our earlier approach to HRT was completely off base? No.  As it turns out, there are many aspects of the WHI that are being questioned and concern is being raised whether its results should be the basis for the current guidelines. Some critics claim it is a “flawed” study – which is a little unkind since it actually is felt to be a very reputable study.  The problem appears to be more related to the way the findings have been applied.  I will be going into more detail in future blogs about this, but the main criticisms have been that most of the women in the WHI were much older than the age women typically go through menopause.  In addition, only one type of estrogen and one type of progestogen were used – which we now know may have led to more adverse effects than the hormone products we recommend today.

However, because the WHI is still considered the “mother of all studies” (it was huge and had all the qualities of what is considered a “landmark” study) and no other comparable studies have been done since, it continues to be the foundation for the current guidelines – so we seem to be stuck with them for now.

Based on the WHI the FDA, as well as the USPSTF, currently advise that only women with severe hot flashes be treated with HRT, and that they should periodically try to wean themselves off the hormones to see if they still need them.  The only other approved indication is the use of low-dose estrogen vaginal creams to treat vaginal dryness – but OTC lubricants and moisturizers should be tried first.  Unlike in the past, hormones are not being recommended as a preventative therapy for any conditions (except for bone thinning and you have to have pretty advanced bone thinning to even be considered a candidate).

I don’t agree with the current guidelines and many menopause experts are also voicing concerns. Part of the reason is that up until 2002 there were many, many studies that found that although hormone replacement slightly increased the risk of breast cancer, it decreased the risk of fractures, heart attacks, strokes and, in some cases, dementia. There has also been much additional research showing that estrogen, when initiated at the time of menopause, can minimize hardening of the arteries and prevent strokes and diabetes.  Estrogen also is extremely effective at preventing the rapid bone loss that occurs within a few years after menopause.  The long-term health impacts from these benefits likely outweigh the potential risks of a slight increase in breast cancer.

Many organizations such as the North American Menopause Society (NAMS) are calling attention to the shortcomings of the WHI-generated guidelines and are updating their recommendations to encourage a more liberal use of HRT.  In their 2017 Position Statement they suggest that women be treated with an adequate amount of estrogen for as long a time as needed, and that treatment should be individualized based on a woman’s personal health risks and preferences. 

The fact that less than ten percent of  American women are taking HRT raises concern that we may start seeing more heart disease, diabetes, and fractures in women who have not been treated with HRT.  I believe that women should be aware of the very convincing data indicating that starting HRT at the time of menopause likely carries way more benefits than risks for most women.  The goal of this website is to inform women of the data that is showing this.