A gynecologist’s guide to menopausal hormone therapy

Symptoms experienced by postmenopausal patients are very individualized, and treatments that patients choose are going to depend on symptom severity as well as the patient’s risk factors and their personal feelings about menopause and medication.

Menopausal hormone therapy requires a customized approach to each patient that considers not only their clinical presentation and symptom severity, but the risks and benefits of hormone replacement, risk factors and the patient’s personal feelings about menopause and medication, according to a Norton Women’s Health gynecologist.

Symptoms experienced by postmenopausal patients are very individualized, and by working together, patients and providers can find treatments that are right for the patient’s condition and comfort level.

“Starting menopausal hormone therapy within six to 10 years of menopause carries a slight risk for healthy patients in the 50 to 59 age range,” said Amy Farrell, M.D., an OB/GYN with Norton Women’s Care. “In older patients, the risk of thrombosis, stroke and other cardiovascular events can get very high.”

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A 10-step guide for menopausal hormone therapy

  • Determine that the patient is truly menopausal and “newly” menopausal — within six to 10 years of their final menstrual period.
  • Identify moderate to severe vasomotor symptoms such as hot flashes and night sweats. Vaginal symptoms may require a different course of treatment.
  • Consider contraindications to menopausal hormone therapy. A history of breast or endometrial cancers, severe active liver disease, history of thromboembolic events or undiagnosed vaginal bleeding are absolute contraindications. Relative contraindications include chronic hepatic dysfunction or family history of breast cancer.
  • Does the patient have a uterus? If not, consider using estrogen alone. If there is a uterus, use progestin to protect from endometrial cancer.
  • Pick an estrogen — transdermal if possible, for the decreased risk of thromboembolic events.
  • Pick a progestin — Prometrium or others if needed.
  • Try to avoid using system and vaginal estrogen simultaneously, if possible.
  • Get the patient to an effective dose that’s helping their symptoms.
  • Consider discontinuing at five years and try to get the patient to age 59. Some will have to go longer because of severe symptoms.
  • Consider tapering as a discontinuation method, but also look at a teeter-totter method if the patient is symptomatic. For symptomatic patients, consider adding a nonhormonal treatment and a selective serotonin reuptake inhibitor (SSRI) so they have something to control their symptoms, according to Dr. Farrell.

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