NAMS: Nonhormone Therapy Position Statement 2023

SUMMARY:

An advisory panel was selected to review current literature regarding nonhormone therapy based on levels of evidence. In the treatment of vasomotor symptoms in women within ten years of menopause and who are not candidates for or who decline hormone therapy, evidence-based nonhormone options such as behavioral therapies, medications such as SSRIs or gabapentin, and weight loss should be discussed and considered.  

Vasomotor Post Menopausal Symptoms  

• Vasomotor symptoms (VMS) 
  • Defined as hot flashes and night sweats  
• Incidence 
  • Mean 7 to 10 years 
  • 30% >10 years 
• Standard Management 
  • Hormone therapy 
  • First line recommended treatment 
  • Underutilized therapy 
• Contraindications 
  • Estrogen sensitive tumors 
  • Coronary artery disease/myocardial infarction history 
  • Stroke 
  • Venous thromboembolism 

Recommended Nonhormone Techniques and Therapies  

• Mind-Body Techniques 
  • Clinical hypnosis 
  • Cognitive behavior therapy 
• Prescription Medications 
  • SSRIs and SNRIs demonstrate mild to moderate improvement 
    • Ecitalopram 10 to 20 mgs/day 
    • Paroxetine salt 7.5 mg/day 
    • Paroxetine 10 to 25 mg/day 
    • Citalopram 10 to 20 mg/day 
    • Desvenlafaxine 100 to 150 mg/day (start at 25 to 50 mg/day) 
    • Venlafaxine 37.5 to 150 mg/day (start at 37.5 mg/day) 
  • Gabapentin 
    • 900 to 2400 mg/day in divided doses (start with 100 to 300 mg at night, add 300 mg at night, then an AM dose of 300 mg) 
  • Fezolinetant 
    • Neurokinin B antagonist 
    • 45 mg/day 
  • Oxybutynin 
    • 2.5 to 5.0 mg twice daily or 15 mg extended release daily 
    • Long term use may be associated with cognitive decline in older adults 
• Weight loss 

NOT Recommended 

• Yoga | Diet | Cooling techniques | Weight loss | Relaxation techniques  
• All dietary supplements/cannabinoids 
• Acupuncture 
• Chiropractic manipulations 
• Stellate ganglion block may alleviate moderate to severe VMS but is associated with risk of transient seizures or bleeding 
• Medical therapies not recommended 
  • Pregabalin 
  • Clonidine 
  • Suvorexant  

KEY POINTS: 

• Vasomotor symptoms occur in up to 80% of postmenopausal women 
• Mean duration 7 to 9 years 
  • >10 years for one third of women 
• Hormone therapy is underutilized in symptomatic women 
• Hormone therapy is the most effective treatment for vasomotor sympytoms and is indicated for  
  • Women younger than age <60 years 
  • Are within 10 years of menopause 
  • Are without contraindications including 
    • Estrogen sensitive malignancies 
    • Coronary artery disease/myocardial infarction 
    • Thromboembolism/stroke 
      • Inherited high risk for thromboembolic disease. 
• Recommended nonhormone therapies: Prescription 
  • SSRIs/SNRIs 
  • Gabapentin 
  • Oxybutynin 
  • Fezolinetant 
• Recommended therapies: Nonprescription 
  • Cognitive based therapy 
  • Clinical hypnosis 
  • Weight loss 
  • Stellate ganglion block 
• Not recommended or insufficient evidence  
  • Supplements or herbal remedies 
    • Soy extracts 
  • Yoga and exercise 
  • Cooling techniques 
  • Cannabinoids 
  • Acupuncture 
  • Chiropractic interventions 

Learn More – Primary Sources: (Level 3) 

The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society 

North American Menopause Society: Hormone Therapy Statement

SUMMARY:

NAMS updated its position statement on hormone therapy, based on an extensive literature review. Hormone therapy (HT) is the most effective treatment for vasomotor symptoms (VMS; hot flashes, night sweats) and genitourinary syndrome of menopause (GSM). The statement has been endorsed by over 20 international organizations.

Contraindications for HT
Potential risks of HT
FDA approved indications for HT
NAMS recommendations for type / regimen / duration of use
NAMS recommendations for special populations and cancer risk
Hormonal therapy dosage / regimens
Key points
Learn more

CONTRAINDICATIONS FOR HT (oral or transdermal)

• Unexplained vaginal bleeding
• Severe active liver disease
• Prior estrogen sensitive cancer (including breast cancer)
• Prior coronary heart disease
• Stroke, MI or VTE
• Personal history/inherited high risk of thromboembolic disease

POTENTIAL RISKS OF HT

Women <60 Years or Who are Within 10 Years of Menopause

• Breast cancer (rare risk) with combined estrogen-progestogen therapy
• Endometrial hyperplasia and cancer with unopposed estrogen
• VTE
• Biliary issues

FDA APPROVED INDICATIONS FOR HT

• Bothersome vasomotor symptoms
• Prevention of bone loss
• Hypoestrogenism caused by hypogonadism, surgical castration or premature ovarian insufficiency
• Genitourinary symptoms

NAMS RECOMMENDATIONS FOR TYPE / REGIMEN / DURATION OF USE

Individualize Type, Dose & Regimen

• For women with a uterus and using systematic estrogen, ensure endometrial protection (Level I)
  • Use adequate dose and duration of a progestogen
    • In WHI, addition of medroxyprogesterone acetate 2.5 mg daily resulted in same risk of endometrial cancer as placebo (hazard ratio 0.81 (95% CI 0.48-1.36)
  • combine conjugated equine estrogens (CEE) with bazedoxifene
• Progestogen therapy not recommended for low-dose vaginal estrogen therapy (ET)
  • Evaluate endometrium if bleeding does occur
• Avoid compounded bioidentical HT given concerns about safety
• Do not use salivary hormone testing to dictate dosing

Individualize Duration

• Premature menopause, either natural or induced <45 years and especially if <40 years
  • Continue HT at least until age 52, which is the median age of menopause (Level II)
• The recommendation to routinely discontinue HT in women aged 65 and older is not supported by data
• Decision to continue >60 years of age includes quality of life, VMS, bone loss/fracture and other medical risks vs benefits

NAMS RECOMMENDATIONS FOR SPECIAL POPULATIONS AND CANCER RISK

Family History of Breast Cancer or BRCA Positive Following Prophylactic Oophorectomy

• Use of HT does not appear to increase the relative risk for breast cancer

• Family history is a risk factor for breast cancer and should be assessed when counseling about HT

Ovarian Cancer

• Recent and current use of hormone therapy is associated with a small increase in serous type of ovarian cancer
  • One additional ovarian cancer death in 1,700 to 3,300 HT users
  • Both combined estrogen-progestogen therapy and ET
  • Risk dissipates within 5 years of discontinuing HT
• After diagnosis of epithelial ovarian cancer, HT does not affect recurrence risk or survival
  • Benefits of use outweigh risks
• Not recommended in hormone-dependent ovarian cancers (granulosa-cell tumors and low-grade serous carcinoma)

Breast and Endometrial Cancer Survivors: Systemic HT for VMS

• Encourage nonhormonal therapies
• Endometrial cancer survivor
  • If VMS not well controlled, may consider HT in conjunction with oncologist
• Breast cancer survivor (especially ER+)
  • Systemic HT should not be offered but if other nonhormonal alternatives have failed, shared decision making that includes an oncologist can be considered

Breast and Endometrial Cancer Survivors: Low-dose Vaginal ET

• Low-dose vaginal ET has minimal systematic absorption and appears to hold minimal to no risk for breast or endometrial cancer
• Endometrial cancer survivor following hysterectomy and successful treatment
  • Consider low-dose vaginal ET in nonhormonal options are unsuccessful
• Breast cancer survivors
  • Decisions regarding low-dose vaginal estrogen should involve the treating oncologist especially if patient is on aromatase inhibitors

Colorectal Cancer

• Overall decreased risk of colorectal cancer in current HT users compared to non-users
  • No benefit associated with prior use

Lung Cancer

• No effect on lung cancer incidence and/or survival

HORMONAL THERAPY DOSAGE/REGIMENS

NOTE: For women with a uterus and using systematic estrogen, ensure endometrial protection with an adequate dose of a progestogen

VSM: Systemic

• Standard Dose
  • Conjugated estrogen 0.625 mg/d
  • Micronized estradiol-17β 1 mg/d
  • Transdermal estradiol-17β 0.0375–0.05 mg/d
• Low Dose
  • Conjugated estrogen 0.3–0.45 mg/d
  • Micronized estradiol-17β 0.5 mg/d
  • Transdermal estradiol-17β 0.025 mg/d
• CEE + SERM
  • Conjugated estrogen 0.45 mg/d and bazedoxifene 20 mg/d
• 19-nortestosterone derivative synthetic steroid
  • Tibolone 2.5 mg/d

Note: Progestin-only medications, testosterone, or compounded bioidentical hormones for the treatment of vasomotor symptoms are not recommended

GSM: Systemic

• Standard Dose
  • Conjugated estrogen 0.625 mg/d
  • Micronized estradiol-17β 1 mg/d
  • Transdermal estradiol-17β 0.0375–0.05 mg/d
• Low Dose
  • Conjugated estrogen 0.3–0.45 mg/d
  • Micronized estradiol-17β 0.5 mg/d
  • Transdermal estradiol-17β 0.025 mg/d

PROGESTOGENS FOR UTERINE PROTECTION – when using standard dose estrogen

• Medroxyprogesterone acetate
  • 2.5 mg po daily for continuous therapy
  • 5 mg daily po with sequential therapy for 12 – 14 days sequentially per 28-day cycle (start day 1 or 16)
• Micronized progesterone
  • 100 mg po daily for continuous therapy
  • 200 mg po nightly for 12 days sequentially per 28-day cycle
  • Formulated with peanut oil – do not use in women with peanut allergies
  • May cause hypnotic effects and should be taken at bedtime

GSM: Local (vaginal, and in the case of creams may also be applied to vestibular area)

• Estradiol-17β ring (releases 7.5 micrograms/d): replace every 3 months
• Estradiol vaginal tablet (10 micrograms/d): place nightly for 2 weeks
  • Maintenance is one tablet 2 times/week
  • Note: this is the corrected dose in ACOG PB 141
• Estradiol-17β cream (0.1 mg active ingredient/g):  2-4 g/d for 1 to 2 weeks
  • Gradually reduce to ½ initial dosage for 1 – 2 weeks
  • Maintenance is 1 g, 1 to 3 times/week
• Conjugated estrogen cream (0.625 mg/g):  0.5–2 g/d for 21 days then off for 7 days
  • In practice during maintenance therapy, most women apply 1 – 3 times /week

KEY POINTS:

• Risks of HT differ depending on type/dose/duration/route/timing of initiation and whether a progestogen is needed
  • Individualize treatment to maximize benefits/minimize risk
  • Reassess periodically
• Women younger than 60 or within 10 years of menopause without contraindications have a favorable benefit-risk ratio for use of HT in the treatment of VMS and reducing bone loss/fracture for those at increased risk
  • Longer duration may be more favorable for estrogen therapy alone vs combined estrogen-progestin therapy based on the WHI RCTs
• Women who begin HT more than 10 years from menopause onset or aged 60 or older have a less favorable benefit-risk ratio, with greater absolute risks of CHD, stroke, thrombosis and dementia
• Low-dose vaginal estrogen therapy is recommended for GSM symptoms not relieved with other therapies
• Nonestrogen therapies like ospemifene and intravaginal DHA are approved for use in postmenopausal women
• Cognition
  • HT is not recommended to prevent cognitive decline
  • Starting HT >65 years has been associated with increased risk for dementia | Normal cognition prior to initiation may attenuate this effect
  • ET may have cognitive benefits if started immediately following hysterectomy with bilateral oophorectomy
  • HT in the early natural postmenopause period does not appear to impact cognitive function

The USPSTF Guidance on the Role of Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons

• The USPSTF assessed the evidence for harms and benefits for chronic disorders such as coronary heart disease, dementia, stroke, fractures, and breast cancer
• The USPSTF concludes with moderate certainty that there is no net benefit in the use of hormone therapy
  • The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons (*D recommendation)
  • The USPSTF recommends against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy (*D recommendation)

*D recommendation Suggestion for Practice: Discourage the Use of This Service

Learn More – Primary Sources:

The 2022 hormone therapy position statement of The North American Menopause Society

NAMS Patient Educational Information: Deciding About Hormone Therapy Use

USPSTF Recommendation: Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons

ACOG Practice Bulletin 141: Management of Menopausal Symptoms

FIGO: Counseling in menopausal women – How to address the benefits and risks of menopause hormone therapy

Lancet: Menopause 2024