Updated IMS recommendations on postmenopausal hormone therapy and preventive strategies for midlife health

Introduction

The past decade has seen marked fluctuations in opinions concerning the merits and risks of postmenopausal hormone replacement therapy (HRT). In July 2002, menopause manage­ment faced a major turning point when the first data from the Women's Health Initiative (WHI) trial were released. This study was categorized as a primary prevention trial for coronary heart disease. However, the mean age at recruitment was 63 years, when menopausal symptoms have usually finished and HRT is rarely started, but this important difference from common clinical practice was not acknowledged at that time. Instead, WHI investigators concluded that HRT was not cardioprotective and that its risk–benefit ratio did not favor the use of postmenopausal hormones for prevention of chronic diseases. As a result, there was a dramatic change in prescription habits following recommendations to reserve HRT for very symptomatic women, and to limit its use to the 'shortest duration needed' and to 'the lowest effective dosage'. This was the atmosphere in which the International Menopause Society (IMS) initiated a Workshop held in Vienna (December 2003) and produced the subsequent IMS Position Paper resulting from the Workshop discussions. Basically, the IMS did not accept some interpretations attributed to the WHI results and, being independent of local or regional constraints imposed by official health authorities, called for a more balanced approach to the scientific data. Because additional information has been accumulated from both arms of the WHI study, from observational trials and from other studies during the following years, the first IMS Statement was updated in 2007, enlarging its scope to menopause manage­ment and adult women's health in general. This revised Statement was formulated in a Workshop held in Budapest in February 2007, in which 30 experts from the various fields of menopause medicine presented the latest information and delegates from 60 National and Regional Menopause Societies from all continents participated in the discussions.
The 2011 revision of the IMS Recommendations is published when the atmosphere around the issue of post­menopausal HRT is much more rational. The pendulum swung back from its peak negative sentiment following more detailed data from the WHI study that demonstrated the importance of the age at initiation and the good safety profile of HRT in women younger than 60 years. Since these were exactly the IMS views expressed in the previous Recommend­ations, the current update is similar in principle to the 2007 version, but with the additional clinical data where needed. It has been produced by a small Writing Group of experts, and not from a formal workshop, but is the considered view of the IMS on the principles of HRT in the peri- and postmenopausal periods. Throughout the Recommendations, the term HRT will be used to cover therapies including estrogens, progest­ogens, combined therapies, androgens and tibolone. The IMS is aware of the geographical variations related to different priorities of medical care, different prevalence of diseases, and country-specific attitudes of the public, the medical community and the health authorities toward menopause management, different availability and licensing of products, all of which may impact on HRT. These Recommendations and the subsequent key messages therefore give a global and simple overview that serves as a common platform on issues related to the various aspects of hormone treatment, which could be easily adapted and modified according to local needs.

Full recommendations

The full text of the 'Updated IMS recommendations on postmenopausal hormone therapy and preventive strategies for midlife health' is available in a number of formats for download.

Print version, as published in Climacteric (PDF)

Spanish version (PDF)

PowerPoint of key points of recommendations