Facts About Menopausal Hormonal Therapy

10 years after the seminal publication of the Women’s Health Initiative trials data¹, certain facts and data have emerged that can help guide us in this so controversial an issue of Menopausal Hormonal Therapy (MHT). The following is a summary of a review published lately in the journal Menopause².

It has always been a truth that MHT is an acceptable option for treating severe early menopausal symptoms. As is the wont of these symptoms, they disappear within 10 years of menopause, thus this treatment is prudent and applicable within this time frame. Such therapy must of course be precluded in the presence of medical problems, foremost of which are blood clots, heart disease, stroke and cancer.

Estrogen replacement alone suffices for a woman who has lost her uterus, whereas progesterone therapy needs to be added for the sole purpose of prevention of endometrial cancer in those who retain theirs. If the symptoms are limited to the vulva, vagina and the bladder, topical estrogen therapy to the affected parts might be enough to soothe the symptoms.

So much is so true, and we must keep in mind that the whole controversy arose not because of questionable beneficial effects, rather, the serious consequences of MHT. Foremost in the mind of most women is the occurrence of breast cancer. The WHI trials demonstrated an increased risk of breast cancer with more than 5 years continued use of the estrogen-progesterone combination therapy. This increased risk was not present in users of estrogen-only preparations, thus suggesting a causal link of breast cancer with progesterone. The data shows that the risk is not that great and decreases after discontinuation of said replacement therapy. Estrogen, whether given alone or together with progesterone, increases the risk of thromboembolic events (TE) such as deep vein thrombosis, pulmonary embolism and stroke, but these occurrences are rare before the age of 59 years.

Thus we have come to accept that combination estrogen-progesterone MHT is proven effective in the management of early menopausal symptoms only (and not for other indications) but should be used for the shortest duration and with the lowest possible dosage. More flexibility is accorded to estrogen only therapy but similar caveats should apply whenever possible.

Fakta Berkenaan Rawatan Hormon Menopause

10 tahun selepas maklumat daripada kajian unggul berkenaan rawatan menopause diketengahkan¹, situasi berkenaan rawatan ini semakin jelas, saperti dipaparkan dalam jurnal Menopause baru-baru ini². Berikut adalah ringkasan tajuk utama.

Terapi hormon untuk menopause (MHT) sungguh berkesan mengatasi gejala awal menopause dan boleh diteruskan selama 10 tahun, iaitu, sehingga simptom-simptom keadaan ini hilang. Rawatan ini tidak boleh digunakan jikalau seseorang wanita mengalami beberapa masalah perubatan, terutama sekali ketulan dalam saluran darah, serangan angina ahmar, sakit jantung dan kanser.

Rawatan ini boleh dibahagikan kepada 3 – hormon estrogen sahaja untuk wanita yang tidak mempunyai rahim, kombinasi hormon estrogen-progesteron bagi mereka yang ada rahim dan krim estrogen setempat jikalau gangguan terhad kepada kemaluan, faraj atau pundi kencing.

Risiko penggunaan MHT ialah kejadian saperti kanser payudara dan kejadian tromboembolik (TE) saperti angina ahmar, ketulan darah dan embolasi paru-paru. Tidak dinafikan yang MHT meningkatkan risiko mengalami kanser payudara, tetapi jumlah kejadian ini kecil dan risiko tersebut hilang selepas rawatan diberhentikan. Lagipun, risiko berlakunya kanser payudara hanya meningkat jika digunakan terapi kombinasi estrogen-progesteron dan bukan estrogen bersendirian. Kejadian TE lebih berkemungkinan berlaku dengan kesemua jenis rawatan oral tetapi jarang dialami sebelum umur 59 tahun.

Dengan ini, MHT didapati sesuai untuk rawatan simptom-simptom awal menopause sahaja tetapi perlu digunakan dalam dos yang paling rendah dan dalam jangkamasa yang paling pendek. Pengawasan untuk gejala kanser payudara dan kejadian TE mesti berterusan.

1. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA 2002;288(3):321-333.

2. Stuenkel CA, Gass MLS, Manson J et al. A Decade After the Women’s Health    Initiative – The Experts Do Agree. Menopause 2012;19(8):846-847.