Hormone Replacement Therapy in Menopause

Indications and Contraindications

The American College of Cardiology recommends that hormone replacement therapy (HRT) for menopause should be limited to women under 60 years old or within 10 years of menopause onset, using the lowest effective dose for the shortest duration necessary to alleviate symptoms 1, 2
In women aged 60 or older, or more than 10 years post-menopause, oral estrogen HRT is associated with an increased risk of stroke 1, 2
HRT should be used primarily for symptom management, not for the prevention of chronic conditions 3

Women with a history of breast cancer, liver disease, myocardial infarction, or known or suspected estrogen-dependent neoplasia should not receive HRT 1, 2
Women with a history of deep vein thrombosis or thrombophilic disorders should also avoid HRT 1, 2

For women with an intact uterus, estrogen plus progestogen or bazedoxifene is recommended 1, 2
For women without a uterus (previous hysterectomy), estrogen-only therapy is recommended 1, 2
Transdermal formulations are preferred due to their lower impact on coagulation 4

The lowest effective dose should be used for the shortest duration necessary to control symptoms 1, 2

Women with premature menopause (before 40) or early menopause (before 45) are at higher risk of stroke 1, 2
For genitourinary symptoms without indications for systemic HRT, low-dose vaginal estrogen therapy is recommended 4
Topical estrogen treatments are not associated with an increased risk of stroke 1, 2

For women with contraindications to HRT, consider:
- Selective serotonin and norepinephrine reuptake inhibitors (SSNRIs) like venlafaxine 4
- Gabapentin for hot flashes 4
- Vaginal lubricants and moisturizers for genitourinary symptoms 4
- Lifestyle and environmental modifications 4