Menopause and hormone therapy

Systemic hormone therapy is the most effective treatment for bothersome vasomotor symptoms and for the genitourinary syndrome of menopause, and it prevents bone loss and fracture. A woman with a uterus needs a progestogen alongside systemic estrogen to prevent endometrial hyperplasia and cancer.

Timing drives the benefit-risk balance. For women under 60 or within 10 years of menopause onset with no contraindications, the balance favors treating bothersome vasomotor symptoms and preventing bone loss. Starting more than 10 years out, or after age 60, shifts the balance unfavorably because the absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia are higher.

Route can be individualized. Transdermal estrogen bypasses first-pass hepatic metabolism, and observational data suggest less venous thromboembolism risk than oral, though randomized comparisons are lacking; micronized progesterone may be less thrombogenic than other progestogens. For genitourinary symptoms alone, low-dose vaginal estrogen is effective with minimal systemic absorption and generally needs no progestogen. Contraindications include unexplained vaginal bleeding, active liver disease, prior estrogen-sensitive cancer including breast cancer, and prior coronary heart disease (including myocardial infarction), stroke, or venous thromboembolism, or high inherited thrombotic risk.

Individualize and reassess periodically. There is no arbitrary stop at age 65, and continuing for persistent symptoms beyond 65 is reasonable with counseling and shared decision-making; breast cancer risk rises with the duration of combined therapy. Separately, do not use hormone therapy to prevent chronic disease: the USPSTF recommends against combined estrogen-progestin, and against estrogen alone after hysterectomy, for the primary prevention of chronic conditions. This applies to asymptomatic women, not to treating menopausal symptoms.