Hormone Therapy for Menopause in Women with Intact Uterus

Indications for Hormone Therapy

The American College of Obstetricians and Gynecologists recommends hormone therapy for women with intact uterus, using the lowest effective dose for the shortest duration possible, primarily for management of vasomotor symptoms and not for prevention of chronic diseases 1, 2
Hormone therapy is indicated for vasomotor symptoms (hot flashes), with estrogen being the most effective treatment, reducing the frequency of moderate to severe symptoms by approximately 75% 2
Hormone therapy is also indicated for vaginal atrophy and genitourinary symptoms, improving symptom severity in 60-80% of women 3, 2

The preferred estrogen component is transdermal estradiol, which avoids first-pass hepatic metabolism, reducing cardiovascular and thromboembolic risks 3
The addition of progestogen is mandatory in women with intact uterus to prevent endometrial hyperplasia and cancer, reducing the risk by approximately 90% 5, 2
Progestogen options, in order of preference, are: progesterone, medroxyprogesterone acetate, and levonorgestrel-releasing intrauterine system 4, 3, 2

The American College of Obstetricians and Gynecologists recommends using the lowest effective dose for the shortest duration possible, with reevaluation every 3-6 months 1, 2, 3
Therapy should not be initiated after age 65 for prevention of chronic diseases, and women who start therapy before age 60 or within 10 years of menopause have a more favorable risk-benefit profile 3

Hormone therapy is contraindicated in women with a history of breast cancer, active liver disease, venous thromboembolism, coronary artery disease, stroke, or undiagnosed abnormal vaginal bleeding 5, 6, 3, 2

For every 10,000 women-years of treatment, there are 8 more cases of invasive breast cancer, 9 more strokes, 12 more deep vein thromboses, 9 more pulmonary emboli, and 20 more gallbladder diseases, but 46 fewer fractures of any type 7, 1

For women with contraindications or who decline hormone therapy, alternative options include paroxetine, venlafaxine, or gabapentin for hot flashes, and low-dose vaginal estrogen for genitourinary symptoms 6, 3, 2

Annual clinical evaluation is recommended to assess adherence and adverse effects, with ultrasound measurement of endometrial thickness and mammography according to standard guidelines 5, 4, 3