Two recent guidelines on menopause management have been published and have already been discussed separately in our web-based educational program. Yet, I felt that head-to-head comparison of both guidelines in regard to postmenopausal hormone therapy (HT) is worthwhile since it shows the small, but somewhat significant differences in approach concerning cardiovascular safety. The NICE guidance details how the interaction between the health-care provider and the individual woman should be executed, and it provides advice on how to present and explain the benefits and the risks of HT in a specific case scenario . The format of the Endocrine Society clinical practice guideline is more formal and general . Dr Stuenkel, the lead author of the Endocrine Society guideline, recently gave an interview to Medscape, which I am quoting in the sections below [3, a personal password is required]. Importantly, the NICE and Endocrine Society papers point at the need to address breast cancer risk, and recommend against the use of HT in high-risk cases.
Both recommendations suggest that the younger age group is the target population for HT. As for the cardiovascular aspects, Dr Stuenkel says that menopausal women with bothersome vasomotor symptoms who are younger than 60 years old or who have been in menopause for less than 10 years should receive estrogen therapy (with a progestogen for women with an intact uterus), provided that they are not at elevated risks for cardiovascular disease. In contrast, NICE states that HT does not increase cardiovascular disease risk when started in women aged under 60 years, and does not affect the risk of dying from cardiovascular disease. NICE believes that the presence of cardiovascular risk factors is not a contraindication to HT as long as they are optimally managed. Since, according to the Endocrine Society, some women are not eligible for HT because of elevated cardiovascular risk, it is suggested that such women at high risk should be treated with non-hormonal therapy for vasomotor symptoms, and that women at moderate risk should receive transdermal estradiol as first-line treatment. Furthermore, this categorization means that cardiovascular risk should be determined individually according to validated risk scores before prescription of HT.
As for thromboembolism, both guidelines disclose a similar approach: NICE advice is to consider transdermal rather than oral HT for menopausal women who are at increased risk of venous thromboembolic disease, including those with a body mass index over 30 kg/m2. The Endocrine Society favors non-oral estrogen in the treatment of menopausal women with an elevated risk for venous thromboembolic disease. When needed, these patients should also receive a progestogen, such as progesterone or dydrogestone, which is more neutral in its effects on coagulation.
The 2016 updated IMS recommendations, while acknowledging the cardioprotective effects of estrogen in women aged < 60 years, do not address the scenario of women who have an elevated cardiovascular risk profile . Yet, the recommendations indirectly deal with this aspect by including the following key message: ‘In women who are recently menopausal and with no evidence of cardiovascular disease, the initiation of estrogen-alone therapy reduces coronary heart disease and all-cause mortality.’ The new IMS document also says that transdermal estrogen therapy should be the first choice in obese women suffering from climacteric symptoms, and that observational studies point to a lower risk with low-dose transdermal therapy associated with progesterone, underlined by a strong biological plausibility.
It therefore seems that prescribing HT to menopausal women < 60 years old who are at higher risk for coronary heart disease is not fully endorsed by some menopause societies. In my view, this reflects too much concern on the alleged safety aspects that are not actually based on well-documented data from good-quality, clinical studies.
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Sarri G, Davies M, Lumsden MA; Guideline Development Group. Diagnosis and management of menopause: summary of NICE guidance. BMJ 2015;351:h5746
Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015;100:3975-4011
Dr Stuenkel’s interview to Medscape
Baber RJ, Panay N, Fenton A, and the IMS Writing Group. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016;19:109-50