Continuing HT until the age of natural menopause
Dr. Kaunitz: Dr. Kapoor brings up the important point of duration of systemic HT. I agree that similar considerations apply both to the healthy 41-year-old who had a hysterectomy for abnormal uterine bleeding and to the 35-year-old who had risk-reducing surgery because of her BRCA1 mutation.
In the 2 cases, both to treat symptoms and to prevent chronic diseases, it makes sense to continue HT at least until the age of natural menopause. That is consistent with 2017 guidance from The North American Menopause Society (NAMS) position statement on the use of systemic HT, that is, continuing systemic HT at least until the age of natural menopause.3 Then at that point, continuing or discontinuing systemic HT becomes discretionary, and that would be true for both cases. If the patient is slender or has a strong family history of osteoporosis, that tends to push the patient more in terms of continuing systemic HT. Those are just some examples, and Dr. Kapoor may want to detail other relevant considerations.
Dr. Kapoor: I completely agree. The decision is driven by symptoms that are not otherwise well managed, for example, with nonhormone strategies. If we have any concerns utilizing HT beyond the age of natural menopause, then nonhormonal options can be considered; but sometimes those are not as effective. And bone health is very important. You want to avoid using bisphosphonates in younger women and reserve them for older patients in their late 60s and 70s. Hormone therapy use is a very reasonable strategy to prevent bone loss.
Dr. Kaunitz: It is also worth mentioning that sometimes the woman involved in shared decision making with her clinician decides to stop systemic HT. In that setting, should the patient start developing new-onset dyspareunia, vaginal dryness, or other genital or sexuality-related concerns, it takes very little for me to advise that she start low-dose local vaginal estrogen therapy.
Dr. Faubion: In either scenario, if a woman were to develop symptoms consistent with genitourinary syndrome of menopause (GSM), would you use vaginal estrogen in addition to the systemic estrogen or alone after the woman elected to discontinue systemic therapy?
Dr. Kapoor: Yes to both, I would say.
Dr. Kaunitz: As my patients using systemic HT age, often I will lower the dose. For instance, the dose I use in a 53-year-old will be higher than when she is 59 or 62. At the same time, as we lower the dose of systemic estrogen therapy, symptoms of vaginal atrophy or GSM often will appear, and these can be effectively treated by adding low-dose vaginal estrogen therapy. A number of my patients, particularly those who are on lower-than-standard doses of systemic HT, are also using low-dose vaginal estrogen therapy.
There is a “hybrid” product available: the 90-day estradiol vaginal ring. Estring is a low-dose, 2-mg, 90-day estradiol ring that is very useful, but it is effective only for treating GSM or vaginal atrophy. A second menopausal vaginal estradiol ring, Femring, is available in 2 doses: 0.05 mg/day and 0.1 mg/day. These are very effective in treating both systemic issues, such as vasomotor symptoms or prevention of osteoporosis, and very effective in treating GSM or vaginal atrophy. One problem is that Femring, depending on insurance coverage, can be very expensive. It’s not available as a generic, so for insurance or financial reasons I don’t often prescribe it. If I could remove those financial barriers, I would prescribe Femring more often because it is very useful.
Dr. Faubion: You raise an important point, and that is, for women who have been on HT for some time, clinicians often feel the need to slowly reduce the dose. Would you do that same thing, Dr. Kapoor, for a 40-year-old woman? Would you reduce the dose as she approaches age 50? Is there pressure that “she shouldn’t be on that much estrogen”?
Dr. Kapoor: No, I would not feel pressured until the patient turns at least 46. I bring up age 46 because the average age range for menopause is 46 to 55. After that, if there is any concern, we can decrease the dose to half and keep the patient on that until she turns 50 or 51. But most of my patients are on replacement doses until the average age of menopause, which is around 51 years, and that’s when you reduce the dose to that of the typical HT regimens used after natural menopause.
Sometimes patients are told something by a friend or they have read something and they worry about the risk of 2 things. One is breast cancer and the other is venous thromboembolism (VTE), and that may be why they want to be on a lower dose. I counsel patients that while the risk of VTE is real with HT, it is the women after natural menopause who are at risk—because age itself is a risk for VTE—and it also has to do with the kind of HT regimen that a patient is on. High doses of oral estrogens and certain progestogens increase the risk. But again, for estradiol used in replacement doses and the more common progestogens that we now use in practice, such as micronized progesterone, the risk is not the same. The same goes for breast cancer. My biggest message to patients and clinicians who take care of these patients is that the rules that apply to women after natural menopause just do not apply to this very different patient population.
Dr. Faubion: Thank you, Dr. Kaunitz and Dr. Kapoor, for sharing your knowledge and experience. ●
Other clinical and counseling considerations
Systemic HT past the age of 65
Dr. Kaunitz: Another practical issue relates to long-term or extended use of systemic HT. It’s not infrequent in my practice to receive mail and faxes from insurance carriers of systemic HT users who are age 65 and older in which the company refers to the American Geriatrics Society’s Beers criteria for potentially inappropriate medication use in older adults,1 suggesting that systemic HT is inappropriate for all women over age 65. In this age group, I use lower doses if I am continuing systemic HT. But the good news is that both NAMS and the American College Obstetricians and Gynecologists indicate that arbitrarily stopping systemic HT at age 65 or for any other arbitrary reason is inappropriate, and that decisions about continuing or discontinuing therapy should be made on an individualized basis using shared decision making. That’s an important message for our readers.
Counseling regarding elective BSO
Dr. Faubion: One final note about elective BSO in the absence of a genetic mutation that predisposes to increased ovarian or breast cancer risk. Fortunately, we have seen rates of oophorectomy before the age of natural menopause decline, but what would your advice be to women or clinicians of these women who say they are “just afraid of ovarian cancer and would like to have their ovaries removed before the age of natural menopause”?
Dr. Kaunitz: If patients have increased anxiety about ovarian cancer and yet they themselves are not known to be at elevated risk, I emphasize that, fortunately, ovarian cancer is uncommon. It is much less common than other cancers the patient might be familiar with, such as breast or colon or lung cancer. I also emphasize that women who have given birth, particularly multiple times; women who nursed their infants; and women who have used combination hormonal contraceptives, particularly if long term, are at markedly lower risk for ovarian cancer as they get older. We are talking about an uncommon cancer that is even less common if women have given birth, nursed their infants, or used combination contraceptives long term.
Dr. Faubion: Dr. Kapoor, what would you say regarding the increased risk they might incur if they do have their ovaries out?
Dr. Kapoor: As Dr. Kaunitz said, this is an uncommon cancer, and pursuing something to reduce the risk of an uncommon cancer does not benefit the community. That is also my counseling point to patients.
I also talk to them extensively about the risk associated with the ovaries being removed, and I tell them that although we have the option of giving them HT, it is hard to replicate the magic of nature. No matter what concoction or regimen we use, we cannot ensure reinstating health to what it was in the premenopausal state, because estrogen has such myriad effects on the body in so many different organ systems.
Reference
1. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-2246.