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Case
The patient is illustrative. Ms. N., 51, reports hot flashes about 10 times a day and night sweats that wake her three or four times a night. Her last menstrual period was 14 months ago. She is exhausted at work and asks whether hormone therapy is "safe." She has an intact uterus. Blood pressure is 124/76 and BMI 26. She doesn't smoke, and has no personal history of breast cancer, heart disease, stroke, blood clots or liver disease, and no unexplained vaginal bleeding. Her mother had breast cancer at age 72. Her most recent mammogram, 6 months ago, was normal.
Question 1: What is the most effective treatment for her symptoms?
The North American Menopause Society's 2022 position statement says that hormone therapy remains the most effective treatment for vasomotor symptoms (hot flashes and night sweats) and for the genitourinary syndrome of menopause, and has been shown to prevent bone loss and fracture (2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel, 2022).
Question 2: Is the benefit–risk balance favorable for her?
According to the statement, for women younger than 60 or within 10 years of menopause onset who have no contraindications, the benefit–risk ratio is favorable for treating bothersome vasomotor symptoms and preventing bone loss. For women who start more than 10 years after menopause or after age 60, it appears less favorable because of greater absolute risks of coronary heart disease, stroke, venous thromboembolism and dementia.
Ms. N. is 51, about 14 months after her last period, has bothersome symptoms and has no contraindications, so she is in the group for whom benefits generally outweigh risks. Her mother's breast cancer after menopause is worth discussing, but on its own it isn't a contraindication.
Question 3: What regimen fits her?
The statement notes that risks differ with the type, dose, duration and route of hormone therapy, when it is started, and whether a progestogen is used. Because she has a uterus, she needs a progestogen with estrogen to protect the endometrium. Options include:
- transdermal or oral estradiol at the lowest dose that controls her symptoms, plus oral micronized progesterone or a levonorgestrel intrauterine device; or
- a combined product.
Therapy should be individualized and reevaluated regularly, and longer use should be for a documented reason, such as persistent symptoms, with shared decision-making.
Question 4: What if she doesn't want hormones?
Nonhormonal options include certain antidepressants (SSRIs or SNRIs), gabapentin and lifestyle measures such as layered clothing and a cool bedroom. They are generally less effective than hormone therapy. Cognitive behavioral therapy can help her cope with symptoms and sleep.
Shared decision-making
The FNP explains the benefits and risks in absolute terms, asks what matters most to her (sleep, work and her worry about breast cancer), and offers written information. Ms. N. chooses transdermal estradiol with oral micronized progesterone.
Follow-up
Review in 3 months for symptom relief, side effects such as breast tenderness or bleeding, and blood pressure. Continue routine breast cancer screening and reassess the need for therapy at least once a year.
Reference
2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767–794. https://doi.org/10.1097/GME.0000000000002028
