Hormone therapy is the most effective treatment for women experiencing menopausal symptoms.
From now on, women can expect more consistent and nuanced advice about hormones from their doctors.
These are two of the main messages from the Danish Society of Obstetrics and Gynecology, which on Tuesday released new guidelines for hormone therapy for menopausal women.
Chief physician Anette Tønnes Pedersen from Rigshospitalet’s gynecological department has led the effort. The new guidelines are based on a review of relevant research on the beneficial effects and potential risks of hormone supplements. She hopes the guidelines will provide more reassurance.
»The most important aspect of the new guidelines is to offer women nuanced and individualized guidance. There is a great need for this«, she says.
Previously, women had to try lifestyle changes to alleviate their symptoms before receiving hormone supplements. That is no longer the case, explains Anette Tønnes Pedersen.
»The woman herself knows when relief is needed. Not her doctor or anyone else. When women consult their doctor, it is because they need relief«, she says.
Charlotte Floridon is a private-practice gynecologist who, together with two professors, peer‑reviewed the new guidelines. She runs two clinics, in Copenhagen and Odense, where she exclusively sees women seeking relief from menopausal symptoms. In Odense, the first available appointment is in August; in Copenhagen, patients “only” have to wait until May.
»It’s tragic that it has to be this way. Far more women than those currently receiving hormone therapy could benefit from it, but the country’s gynecologists don’t have the capacity to help everyone. We need general practitioners to step up. I really hope they will now that we have new guidelines they can lean on.«
According to the new guidelines, there is evidence that estrogen supplements alleviate symptoms such as hot flashes and night sweats. Fewer hot flashes lead to better sleep, which can help with cognitive issues and fatigue. There is also evidence that local estrogen treatment in the vagina alleviates issues such as burning, itching, and dryness. However, there are not enough research studies to conclude whether estrogen supplements alleviate symptoms such as joint and muscle pain, explains Anette Tønnes Pedersen.
The new guidelines make it clearer that women can benefit from hormone therapy in the years leading up to their last menstruation, when many experience symptoms. Typically, this would be around the mid-40s, but it can also be earlier.
However, there is still a window for hormone therapy. Women over 60 or those who have not had a period for more than 10 years are not recommended to start hormone therapy. Their risk of blood clots is slightly increased.
Thorough work
Charlotte Floridon highlights the quality of the guidelines.
»The data behind them is incredibly thorough and well-researched. All relevant literature has been considered, and I think they have reached an excellent conclusion. They address all the major questions and emphasize an individualized approach to hormone therapy, based on each woman’s symptoms and medical history«, assesses Charlotte Floridon.
She emphasizes that the guidelines clearly state that when estrogen is administered through the skin, there is no significant health risk, neither for cardiovascular disease, cancer, nor other conditions.
Many women fear developing breast cancer as a result of hormone therapy during menopause. This fear largely stems from a widely-publicized American study from 2002, which later proved to be flawed. Specifically, the risk of breast cancer increases from 10 percent to 11-12 percent after five years of treatment with estrogen and gestagen/progesterone in women over 50 at the start of treatment.
She is also pleased that the ’estrogen test’ has found its way into the guidelines. It is suggested that doctors offer women a trial of hormone therapy for a few months to see if it helps with their symptoms.
»It is completely risk-free and can determine whether the symptoms are due to menopause or if the doctor and patient need to look for the cause elsewhere. If it helps, the woman has a good basis for making her own decision«.
Testosterone is an option
For the first time, the guidelines address the use of the male hormone testosterone. The hormone is present in small amounts in women’s bodies and decreases along with estrogen during menopause. The authors of the guidelines do not bring it up because it is a direct recommendation for women to receive testosterone, emphasizes Anette Tønnes Pedersen, but as a consequence of increasing demand.
There is evidence that women with reduced libido after menopause can benefit from a small testosterone supplement.
»It works for half of them. Reduced libido can be caused by factors other than a lack of testosterone«, points out Anette Tønnes Pedersen.
Charlotte Floridon is enthusiastic about the guidance on how doctors should administer testosterone. The deficiency can manifest as low or no libido, reduced sensitivity to touch and stimulation, vaginal dryness, lack of satisfaction and orgasm, as well as pain during intercourse.
»It is important to dose testosterone correctly to achieve the desired effect without too many side effects«, explains Charlotte Floridon.
Testosterone therapy is an example of one of the points in the new guidelines that makes general practitioner Maria Krüger somewhat cautious. She is the acting chair of the Danish College of General Practitioners (DSAM), the professional association for general practitioners.
»Testosterone is not approved for treating women and can therefore only be prescribed ’off label’. My immediate stance is that testosterone should still be prescribed by specialists and not in general practice«, she says, adding that there may also be other cases where it would be appropriate to refer to a gynecologist.
That said, she warmly welcomes the guidelines and predicts that most general practitioners will now feel confident and capable of managing routine hormone therapy based on them.
»The new guidance has been really in demand! Especially over the last two years, we’ve seen a big influx of women who’ve realized that menopausal symptoms can be eased with hormone therapy. We can’t send all of them to a gynecologist, so it’s clear we need to be able to help in general practice,« she says.
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