Current recommendations: what is the clinician to do?

Menopausal hormone therapy (HT) has complex biologic effects but continues to have an important clinical role in the management of vasomotor and other menopausal symptoms. The rational use of menopausal HT requires balancing the potential benefits and risks of treatment. Findings from the Women's Health Initiative (WHI) and other randomized clinical trials have helped to clarify the benefits and risks of HT and have provided insights to improve decision making. Several clinical characteristics have utility in identifying women for whom benefits of HT are likely to outweigh the risks. Age and time since menopause are strong predictors of health outcomes and absolute risks associated with HT, and differences by age have been particularly apparent for estrogen alone. In the WHI trial of conjugated equine estrogens (CEE) alone, younger women (50-59 years) had more favorable results for all-cause mortality, myocardial infarction, and the global index, but not for stroke and venous thrombosis. Age trends were less clear for CEE + medroxyprogesterone acetate, owing to increased risks of breast cancer, stroke, and venous thrombosis in all age groups. Absolute risks of adverse events were lower in younger than in older women in both trials, however. Other predictors of lower vascular risk from HT include favorable lipid status and absence of the metabolic syndrome. Transdermal administration may be associated with lower risks of venous thrombosis and stroke, but additional research is needed. The use of risk stratification and personalized risk assessment offers promise for improved benefit-risk profile and safety of HT. One approach to decision making is presented. Key elements include: assessment of whether the patient has moderate to severe menopausal symptoms, the primary indication for initiating systemic HT (vaginal estrogen may be used to treat genitourinary symptoms in the absence of vasomotor symptoms); understanding the patient's own preference regarding therapy; evaluating the patient for the presence of any contraindications to HT, as well as the time since menopause onset and baseline risks of cardiovascular disease and breast cancer; reviewing carefully the benefits and risks of treatment with the patient, giving more emphasis to absolute than to relative measures of effect; and, if HT is initiated, regularly reviewing the patient's need for continued treatment.