Hormonal treatment of menopause (HRT) in 2022: what do American recommendations tell us?

New recommendations from the American Menopause Reference Society (NAMS) are paving the way for more and more hormone replacement therapy (HRT) prescriptions in the USA. These new recommendations have caused a stir, not least because they come from the country of origin of the 2002 Women's Health Initiative (WHI) study, which led to a drop in HRT prescriptions not only in North America, but also in Europe. New studies published since then largely call into question the conclusions of this study, and have led to the long-awaited updating of American recommendations.
Let's recall a few figures: in the United States, around 40% of women were taking HRT at some point in their menopause in 2001, compared with 12% now, as a result of this study. In France, the figure has fallen from 35% in 2001 to 7% today, and is steadily declining, while in the United States we are now seeing an increase in HRT prescriptions, which should be accentuated by these new recommendations!

An overview

The latest recommendations on HRT from the National American Menopause Society (NAMS) date back to 2017, and in July 2022, after an exhaustive review of recent literature, the new recommendations have just been published. They come exactly 20 years after the publication of the randomized cardiovascular primary prevention study WHI (Women Health Initiative) in 2002, which led to the major international drop in HRT prescribing.

These new recommendations are now much less restrictive, reiterating the major benefits of HRT in early menopause in terms of improving quality of life and preventing fracture risk, and emphasizing the benefits of HRT in early menopause, with no real age limit on continued prescribing, while constantly assessing the benefit/risk balance on a personalized basis. We also remind you that there is no time limit for prescribing local estrogens in the context of Genitourinary Menopause Syndrome (GMS).
Let's take a closer look at the highlights of these new recommendations.

The highlights of the new NAMS recommendations, as published in English this July 2022 in The 2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel, can be summarized, translated and clarified as follows.
(published in Menopause: The Journal of The North American Menopause Society Vol. 29, No. 7, pp. 767-794)

- On prescribing HRT :

- HRT remains the most effective treatment for vasomotor symptomatology, Genitourinary Syndrome of Menopause (GMS), prevention of bone loss and fractures.

- Personalization and shared decision-making, with regular reassessments, remain the key to individually determining the benefit/risk balance, with advice on the use of the appropriate dose, duration, regimen and route of administration to relieve symptomatology and achieve the desired objectives.

- HRT does not have to be stopped at age 60 or 65, and can be continued after age 65 if flushing persists, to improve quality of life or prevent osteoporosis, after assessment of the benefit-risk balance.

- For women with Genitourinary Menopause Syndrome (GMS), local estrogens or non-estrogenic treatments can be used at any age, and continued if necessary.


- On Premature Ovarian Insufficiency (POI):

- Women with early or anticipated menopause (before age 40-45) or Premature Ovarian Insufficiency (< age 40) are at greater risk of bone loss, cardiovascular disease, affective and cognitive disorders due to hypo-oestrogenism. HRT is recommended at least until the classical age of menopause, unless there is a contraindication to its use.


- On risk assessment of HRT:

- Risk stratification according to age and time of installed menopause is recommended.

- The benefits of HRT outweigh the risks in symptomatic, healthy women who are under 60 and within 10 years of settled menopause.

- Transdermal routes and lower doses can reduce the risk of venous thromboembolism and stroke.

- There are few high-quality studies (randomized trials and controlled trials) on the risks of continuing HRT in women over 60 or 65, although observational studies suggest a rare potential risk of breast cancer with longer HRT follow-up.

- For some women after breast and endometrial cancer, observational data show that the low-dose use of local vaginal estrogens, for those who do not respond to apparent non-hormonal treatments, is safe and greatly improves their quality of life.

- The risk of breast cancer does not increase significantly with combined estrogen-progestin HRT in the short term, and would decrease with estrogen alone.

- Preparations of bio-identical compounds present a safety problem in the absence of minimum government regulation and monitoring (overdosing, underdosing, presence of impurities, lack of sterility, lack of scientific efficacy, safety and lack of risk disclosure).

Conclusion

It is to be hoped that these American recommendations, which are increasingly in line with those of the International Menopause Society (IMS) and the Groupe d'étude sur la Ménopause et le Vieillissement Hormonal (GEMVI), will contribute to this movement to reconsider HRT and help more women gain access to it, both abroad and in France, to enable them to live better this often complicated and impactful period of life for many of them.


source: The 2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel
Link: https://www.menopause.org/docs/default-source/professional/nams-2022-hormone-therapy-position-statement.pdf