FDA Approved Indications for MHT
Who: Healthy women who are within 10 years of menopause OR younger than 60 and do not have contraindications
• Vasomotor Symptoms: First-line therapy for appropriate candidates
• Vulvovaginal Atrophy (VVA) / GSM: shown to effectively restore GU tract anatomy, increase superficial vaginal cells, reduce vaginal pH, and treat symptoms of VVA
• Prevention of Bone Loss: RCTs show MHT prevent bone loss and reduce fractures in postmenopausal women
• Premature hypoestrogenism: approved for women with hypogonadism, POI, premature iatrogenic menopause without contraindications
Initiating Systemic MHT for Vasomotor Symptoms
Step 1: Is patient aged 50-59 or within 10 years of menopause with moderate to severe VMS?
Step 2: Assess Contraindications: Hx estrogen-sensitive breast or endometrial cancer, CHD, Previous VTE or inherited high-risk thrombophilia, Previous stroke or TIA, Active liver disease (severe), Unexplained vaginal bleeding, Porphyria cutanea tarda, Hypertriglyceridemia Relative contraindications: endometriosis, leiomyomas, migraines (all may worsen on hormone therapy)
Step 3: Assess patient’s baseline risk Cardiovascular —> 10 year ASCVD Breast —> Gail Model
Step 4: Use lowest dose estrogen necessary to relieve symptoms
Step 5: Uterus? Add systemic progesterone
Step 6: Assess for side effects of therapy, adjust dose as needed lower dose = fewer side effects yearly mammography vaginal bleeding requires endometrial biopsy
Step 7: Reassess symptoms and risk score annually
Step 8: Discontinue Recommend ≤ 5 years therapy, not beyond age 60 Taper slowly to reduce symptom recurrence
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