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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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• American College of Obstetricians and Gynecologists. Management of Menopause Symptoms. ACOG Practice Bulletin No. 141. Obstet Gynecol 2014;123(1):202- 211

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• Manson JE, Chlebowski RT, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013 Oct;310(13):1353-68.

• Rossouw JE, Manson JE, Kaunitz AM, Anderson GL. Lessons learned from the Women’s Health Initiative trials of menopausal hormone therapy. Obstet Gynecol. 2013;121(1):172.

• Jaya M. Mehta, Rebecca C. Chester, and Juliana M. Kling. The timing hypothesis: Hormone therapy for treating symptomatic women during menopause and its relationship to cardiovascular disease. Journal of Women’s Health.May 2019.705-711.

• Mariana Garcia. Cardiovascular Disease in Women. Circulation Research. Volume: 118, Issue: 8, Pages: 1273-1293, DOI: (10.1161/CIRCRESAHA.116.307547)

• Leon R. Step by step approach to determine the safety of prescribing hormone replacement therapy. The University of British Columbia Continuing Professional Development Faculty of Medicine. June 20, 2017. https://

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