Menopause Treatment: Guidelines for Hormone Therapy and Heart Health

New guidelines for the care of perimenopausal and postmenopausal women in Canada have been released, backed by new data to help doctors know when to prescribe menopausal hormone therapy — and when it may not be worth the potential risks.

After menopause, women are at greater risk for a number of health problems, including cardiovascular disease. Doctors want to be sure that any treatment a patient undergoes due to menopause does not further increase these risks.

The updated guidelines state that menopausal hormone therapy is the most effective treatment for relieving menopausal symptoms.

The researchers found that the long-term data showed that short-term menopausal hormone therapy did not lead to increased cardiovascular risk when properly prescribed to women who were not at high risk for heart problems.

However, if women begin menopausal hormone therapy 10 or more years after reaching menopause, they may be at increased risk for adverse cardiac events.

Dr. Beth Abramson, a cardiologist, professor at the University of Toronto and one of the authors of the new guidelines, told in a phone interview that every patient has risks and circumstances to weigh, but that these guidelines help physicians have the tools to understand them.

« There have been several studies and reviews that have been published over the past few years to appropriately inform and empower healthcare providers with the information needed to have a conversation with their patients, » she said.

“In women under 60 who started menopausal hormone therapy shortly after their last menstrual period, there does not appear to be an increased risk of cardiovascular disease. And we found that in general the risk of adverse events, including stroke, is low over the next few years. »


Menopause marks the end of the stage in a woman’s life during which she has menstruation and can become pregnant, usually experienced in midlife.

During this transition, the body’s production of estrogen and progesterone varies greatly, and after menopause a woman’s body will produce much less estrogen. Menopause can sometimes be triggered by the removal of the ovaries or certain ovarian diseases or cancers.

While some women experience few symptoms during the menopausal transition or perimenopausal years, others may experience a range of symptoms, including hot flashes, vaginal dryness, problems sleeping, difficulty controlling their bladder, mood swings and chills, among others.

« If a woman has these symptoms and they are severe, treatment may be indicated for someone’s quality of life, » Abramson said.

According to Mount Sinai Hospital, about 80% of women experience symptoms of menopause and 20% of these women experience severe symptoms.

According to the guidelines, the most effective treatment for people with severe symptoms is menopausal hormone therapy (MHT).

It works by giving postmenopausal women estrogen, usually combined with progesterone, which the body no longer produces.

« It restores estrogen that is depleted or drops when a woman’s body changes after quarantine, » Abramson said.

But there are considerations to make when prescribing MHT.

“Estrogen is a hormone, and a hormone, by definition, has multiple effects on the body,” Abramson said. « And the problem with estrogen is that there is an increased risk of blood clots in the legs and lungs, still small but significant. We call this venous thromboembolism. This has to be weighed against the risk of benefit for that individual patient.

“And so our guidelines looked at the evidence before us. I think we are much more informed than ten years ago.


The new guidelines, written in collaboration with the Society of Obstetricians and Gynecologists of Canada and presented this weekend at the Canadian Cardiovascular Congress in Ottawa, are aimed at physicians, family physicians, nurses, pharmacists and other healthcare professionals. health.

The researchers searched relevant studies published on PubMed, MEDLINE and the Cochrane Library between 2002 and 2020 to update the guidelines.

They found that short-term menopausal hormone treatment was not correlated with increased cardiovascular risk in appropriately selected patients.

Abramson explained that short-term means MHT is not taken for an extended period or indefinitely.

« So we’re not talking about 10 years of therapy, for example, » she said. « Most of the data suggesting safety is from women who took about five years of treatment and then stopped. »

The data they reviewed continued to follow patients for years after stopping MHT, up to 18 years later in some studies, to gauge whether there were any long-term risks.

These studies showed that « there is no increased risk of heart attack or stroke in these women, » Abramson said.

The guidelines suggest that doctors who have decided that MHT is right for their patient should prescribe the lowest dose of estrogen that still treats an individual’s symptoms, to minimize the risk of stroke and blood clots. .

The researchers also found that providing MHT to women who had reached menopause early and continuing this therapy through middle menopausal age appeared to reduce the risk of adverse cardiovascular effects.

The average age of menopause is around 51 years old.

Previous research has shown that women who begin to experience menopause prematurely may be at increased risk for coronary heart disease.

“We certainly know that women over the age of 60, who have been absent 10 years after menopause, have a higher risk of (blood) clotting, and we do not recommend menopausal hormone therapy in general (for them) “, says Abramson.

She added that it’s important to note that MHT is intended for the relief of symptoms associated with menopause, not for the purpose of preventing cardiovascular disease, and is not recommended for this purpose.

Abramson noted that more research still needs to be done to assess MHT’s method of delivery.

“There is a lack of high-quality data looking at what types of estrogen we should give our patients, either orally or in a patch on the skin, for women who are at average cardiovascular risk, and I think there is room for ongoing research to assess this,” she said.

While the new guidelines themselves aren’t too different from the old 2014 guidelines, they have a lot more data to back them up, Abramson said, particularly in weighing individual risks and benefits.

Many women will never need MHT, but the option is there for those who do. This ongoing research helps ensure that doctors are able to help patients make these decisions, experts say.

« I think a woman who has symptoms should talk to her doctor, because we have data to have an intelligent, informed discussion to make sure that woman is aware of the risk versus the benefit, » Abramson said.

« If we don’t discuss, we can’t process. »


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