Hormonal therapy for menopausal symptoms and quality of life

Menopause is a natural biological process that occurs at an average age of 51 years, with 95% of women between 45 to 55 years old becoming menopausal. Menopause is often defined as when a woman has not had any vaginal bleeding for a year. Women experience physiological changes in response to cessation of their ovarian function. Symptoms associated with menopause include hot flushes (or flashes), vaginal atrophy, and, for some women, mood lability. With increasing life expectancy, women may spend a quarter to a third of their life after menopause and the symptoms can compromise their life and livelihood [1]. Few data are available to elucidate the burden associated with menopause-related symptoms and quality of life in the peri- or postmenopausal period during the transition to menopause. The multicenter study published in this volume by Panichkul et al. used a standard menopause rating scale, a Menopause-Specific Quality of Life questionnaire, and other quality of life measures to estimate the burden of problems [2]. These investigators found that psychoemotional distress, loss of libido, musculoskeletal pain, and hot flushes are the most common symptoms, occurring in more than 75% of participants. These symptoms compromise the quality of life of the participants [2].

Hormonal therapy has been implicated to reduce menopausal symptoms and can bring about a better quality of life [3]. Before the study by the Women’s Health Initiative (WHI), hormonal therapy was also often prescribed to prevent coronary heart disease (CHD) and osteoporosis, as a result of epidemiological data demonstrating a protective effect of estrogen on the heart and bone [4]. However, data from the WHI hormone therapy trials in approximately 27,000 postmenopausal women, showed a number of adverse outcomes, including an excessive risk of CHD, stroke, venous thromboembolism, and breast cancer. Therefore, the use of hormonal therapy has to balance its risks and benefits [5, 6]. Clinical practice guidelines of The Endocrine Society recommend an individualized approach to treatment founded upon determining an individual woman’s baseline cardiovascular and breast cancer risks before starting therapy [7]. The Endocrine Society recommends hormone therapy to manage menopausal symptoms, but not to prevent cardiovascular disease, osteoporosis, or dementia [7, 8].

Panichkul et al. compared the change in the menopause-related symptoms and quality of life scores of women with moderate-to-severe menopause-related symptoms who received and who did not receive hormone replacement therapy [2]. They found that the quality of life of the menopausal women can improve over time. Therefore, it seems logical to start hormone therapy for short-term treatment of healthy, symptomatic women during the pre- or perimenopausal period. Women should be assessed in advance of treatment for contraindications to hormonal therapy including a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event or stroke, and active liver disease. The duration of hormonal therapy can be reviewed on an individual basis as the menopausal symptoms may improve as a matter of course over time.