NAMS Position Statement

Practical Considerations of the North American Menopause Society (NAMS) Position Statement:

Wulf H. Utian, MD, PhD, DSc(Med)

Vasomotor Symptoms: Hot flashes and Night Sweats

ET (or EPT for women with an intact uterus) is the gold standard for treatment of vasomotor-related symptoms (hot flashes and night sweats) and hence the drug of choice, provided there is no reason not to prescribe.

ET= Estrogen Therapy

EPT= Estrogen and Progesterone Therapy

Vaginal Symptoms

The cause of vaginal atrophy–related symptoms is estrogen deficiency, and the most appropriate treatment is local ET. Low-dose intermittent application of local ET is exceptionally safe and there is little evidence for adverse effects.

Sexual Function

Local ET is excellent for dyspareunia (painful intercourse). There is little evidence that ET or EPT will aid sexual desire disorder, so the latter is not an indication for ET/EPT.

Urinary Health

In the presence of vaginal atrophy, local ET is recommended for symptoms of frequency and urgency in the absence of painful urination. If the latter is present, suspect a urinary tract infection and treat accordingly. ET may be of value in reducing recurrent episodes of the latter.

There is no evidence to support systemic ET or EPT for the alleviation of true stress urinary incontinence.

Change in Body Weight/Mass

Reassure women that current HT usage is not a cause of weight gain.

Quality of Life (QOL)

NAMS is conservative in its statement regarding QOL. There is, however, good evidence for an improvement in health-related QOL in symptomatic women treated with hormones. My own research and clinical experience also make me believe that true global QOL — the sense of enhanced well-being — is positively affected by HT, but I will concede that further research remains necessary.

Osteoporosis

I do not believe that there can be any doubt that HT reduces bone loss and fractures at all sites, even in women who were not bone deficient at the time of commencing therapy. Whether HT is prescribed for this indication, however, is one of the biggest challenges facing the clinician in balancing risk and benefit to the individual woman.

Cardiovascular Effects

Three primary cardiovascular effects are discussed in the paper: coronary heart disease (CHD), stroke, and venous thromboembolism (VTE).

Coronary heart disease. This is the second most contentious issue regarding the use of postmenopausal HT. The short answer is that women who reach menopause at the typical age and who start HT within no more than 5 years of menopause are likely to gain some CHD protection. But, starting HT 10 or more years beyond menopause will likely increase risk. The absolute risks are rare, but this has to be part of the discussion.

Fortunately, virtually all symptomatic women are in close proximity to menopause, so timing is not a real point of debate. The only reason for beginning systemic HT a long time after menopause would be for protection against osteoporosis, and in that context, topics for discussion include risk, benefit, and alternate bone-sparing therapies.

The bottom line here seems to be that for women in close proximity to menopause, the longer they remain on HT, the greater the protection. On the other hand, remaining on EPT for a long time adversely affects breast cancer risk, so here is another difficult area for clinical resolution.

Stroke. Hemorrhagic stroke (bleeding within the brain) is not an issue. But the WHI EPT and ET trials demonstrated an increased risk of ischemic stroke (decreased blood supply to the brain): 8 additional strokes per 10,000 women per year of EPT use and 11 additional strokes per 10,000 women per year of ET use when data from all the age groups in the entire cohort were analyzed. Younger women in the WHI (aged 50-59 years at study entry) had no significant increase in risk of stroke. So, even though the risk of stroke in older women is rare, this is a serious event and women with risk factors for cardiovascular disease should usually not be considered for HT. Nor can HT be considered for younger women for stroke prevention.

Venous thromboembolism(VTE). The risk of VTE for all women starting HT is rare, and growing evidence suggests that women with a prior history of VTE or women who possess factor V Leiden are at increased risk for VTE with HT use.

Although there are some suggestions that nonoral estrogen (transdermal) use may be safer, the data are observational and the jury is out. I personally feel that a woman at high risk for VTE who insists on using HT for severe menopause-related symptoms — and is nonresponsive to alternative treatments — should be given a nonoral preparation even as we await the evidence.

Diabetes Mellitus (DM or Type 2 Diabetes)

DM is not a contraindication for HT. Limited evidence suggests that HT may reduce the incidence of DM, but this is not a reason within itself to prescribe. When prescribing estrogen for a woman with DM, nonoral preparations may be preferred because of their reduced impact on raising triglycerides.

Endometrial Cancer

Unopposed estrogen significantly increases the incidence of endometrial cancer in women with an intact uterus. With rare exceptions, these women must receive added progestogen.

Breast Cancer

The most contentious area of debate — and the source of the most fear — when considering HT involves the risk of breast cancer. With EPT, use beyond 5 years is associated with increased risk, even though the absolute risk falls into the rare category. This risk needs careful explanation to women, and the decision to assume the risk is a personal one.

Use of HT for less than 5 years does not seem to have a major impact on breast cancer. Evidence suggests that EPT may negatively affect the diagnostic interpretation of mammograms, which could lead to further, costly diagnostic tests, including biopsy.

Mood and Depression

As discussed above under QOL, ET can enhance the sense of well-being. Progestogens may actually induce symptoms similar to premenstrual syndrome. In either event, there is no evidence to justify use of HT as an antidepressant.

Cognitive Aging/Decline and Dementia

As the NAMS statement says: “Memory complaints are common in midlife, but findings from well-characterized cohorts suggest that natural menopause has little effect on memory performance or other areas of cognitive function.” Similarly, there is little evidence for HT use to restore memory or prevent or treat Alzheimer’s disease.

Premature Menopause and Premature Ovarian Failure

This is an area with inadequate study, but limited evidence favors these women being prescribed HT at least up to the typical age of menopause (51 years). Thereafter, the decision becomes the same as for all other women.

Total Mortality

HT may reduce total mortality when initiated soon after menopause.

About The North American Menopause Society

Founded in 1989, The North American Menopause Society (NAMS) is North America’s leading nonprofit organization dedicated to promoting the health and quality of life of women through an understanding of menopause. Its multidisciplinary membership of 2,000 leaders in the field – including clinical and basic science experts from medicine, nursing, sociology, psychology, nutrition, anthropology, epidemiology, pharmacy, and education – allows NAMS to be uniquely qualified to provide information that is both accurate and unbiased, not for or against any point of view.

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