Postmenopausal Hormone Therapy: Benefits, Risks, and Who Should Consider It

Postmenopausal Hormone Therapy (PHT) has undergone several important stages throughout its history. In 1966, following the publication of the highly influential book Feminine Forever and based on the findings of the first epidemiological studies, PHT was considered appropriate for all menopausal women, in all circumstances, as a lifelong means of preserving "eternal femininity." Later, after additional research was evaluated, recommendations changed, and PHT was considered suitable only for selected women with severe, complicated menopausal symptoms and only for a short period, usually not exceeding 1–3 years. Today, after re-evaluating both historical and contemporary evidence-based data, clinical practice has reached a balanced approach. As the well-known saying suggests, the golden mean is often the best solution. The Impact of PHT on Women's Health and Quality of Life PHT is individualized and is particularly appropriate for women younger than 60 years of age during the first 10 years after menopause, provided there are clinical indications. After the age of 65 years, continuation of PHT is generally not recommended; however, the benefit-risk ratio should be assessed individually in every case. PHT is recommended as first-line therapy for vasomotor symptoms, for the prevention and treatment of postmenopausal osteoporosis during the first 10 years after menopause, for women at increased risk of osteoporosis and fractures, and for the treatment of genitourinary syndrome of menopause using local low-dose estrogen therapy. PHT remains the most effective treatment for improving the quality of life of women experiencing early menopausal symptoms, including hot flashes, excessive sweating, and palpitations. The optimal time to initiate PHT is during the first or second year after menopause, provided there are no contraindications. The optimal candidates are healthy women younger than 60 years of age who are within 10 years of menopause. They generally do not have an increased cardiovascular risk and have no history of cardiovascular disease or breast cancer. The main pharmacological principle is to achieve the greatest therapeutic benefit using the lowest effective hormone dose. Treatment is initiated with the minimum effective dose of estradiol, and if the clinical response is insufficient, the dose is gradually increased until the desired therapeutic effect is achieved. The safest route of estrogen administration is transdermal, as it is associated with a lower risk of deep vein thrombosis, a risk that is already low among healthy women younger than 60 years. Women who have undergone hysterectomy require estrogen therapy alone. In women with an intact uterus, progestogens must be prescribed to prevent endometrial hyperplasia and endometrial cancer. Progesterone and dydrogesterone are considered the most physiological options because they do not increase the risk of breast cancer or cardiovascular disease. Effective treatment of the genitourinary syndrome of menopause—including vulvar atrophy, vaginal dryness, dyspareunia, pruritus, and urinary symptoms—is virtually impossible without estrogen therapy. In this setting, phytotherapy, multivitamins, homeopathy, and other treatments with questionable efficacy, whose mechanisms often rely primarily on the placebo effect, are not effective. These alternative therapies provide only minimal relief of vasomotor symptoms and are almost ineffective in the prevention and treatment of osteoporosis. Estradiol deficiency is the most important factor in the pathogenesis of postmenopausal osteoporosis; therefore, PHT remains the first-line intervention for both prevention and treatment, particularly in women at increased risk. Clinical studies have demonstrated that PHT is highly effective in the treatment of postmenopausal osteopenia and osteoporosis. Considering the balance between cost, effectiveness, and adverse effects, no other treatment offers comparable benefits. PHT reduces not only the risk of vertebral fractures but also the risk of osteoporotic hip fractures. Estrogen deficiency also contributes to an increased risk of cardiovascular disease. Studies have shown that bilateral oophorectomy before menopause significantly increases not only the risk of cardiovascular disease and cancer but also mortality related to these conditions. Randomized placebo-controlled clinical trials and comprehensive systematic reviews have demonstrated that estrogen-only PHT administered during the postmenopausal period reduces the risk of myocardial infarction and all-cause mortality. Although a cardioprotective effect has not been conclusively demonstrated for combined estrogen-progestogen PHT, mortality among women receiving this treatment remains lower than in the general population. Patient Monitoring and the Importance of a Healthy Lifestyle When prescribing PHT, national healthcare screening programs should be followed. Cervical cytology (Pap smear) should be performed every three years, and mammography every two years. If abnormalities are detected, the frequency of follow-up examinations should be individualized. The physician responsible for monitoring the patient should reassess the risks and benefits of continuing PHT annually and discuss ongoing treatment with the patient. It is equally important to emphasize the value of a healthy lifestyle, including education about healthy eating according to nutritional guidelines and the benefits of regular physical activity. Women should be encouraged to reduce excess body weight, stop smoking, and avoid excessive alcohol consumption. These lifestyle factors have a substantially greater impact on reducing the risk of cardiovascular disease and breast cancer than the uncertain contribution of PHT itself as a potential risk factor. Heraldas Stankevičius, Lithuanian University of Health Sciences, Department of Obstetrics and Gynecology Source: Lithuanian Doctor's News, No. 6.