Five tips to help you prescribe first-line hormone therapy with confidence

Hormone therapy has been around since the mid-20th century, but it took time to catch on. In 2002, a study by the Women's Health Initiative (WHI) concluded that hormone therapy significantly increased the risk of cancer—arousing caution among doctors and fear among patients. However, its conclusions have been disputed in several subsequent studies.Over the past five years, meanwhile, the use of hormone therapy to reduce the symptoms of menopause has seen a resurgence in popularity. However, some front-line doctors are still reluctant to offer this treatment or even to broach the subject of menopause with their patients.A survey by the Canadian Menopause Foundation, conducted in 2022 of more than 1,000 women aged 40 to 60, revealed that while 41% of participants had sought advice from their family doctor about menopause, 72% of them felt that the advice received was not useful or only slightly useful. In addition, 40% of women thought their symptoms were not sufficiently treated.Obstetrician-gynecologists Drs. Jeanne Bouteaud of the University of Montreal Hospital Centre and Radomir Jarcevic of the Maisonneuve-Rosemont Hospital in Montreal have several tips for front-line doctors to help them prescribe treatment without fear.Read: Prescribing sex hormones: A pragmatic primer for 2023Five solutions:Take the lead and broach the subject of menopause and its symptomsAccording to the Canadian Menopause Foundation survey, more than half of participants consider menopause a taboo subject—making it likely many patients won't bring up the subject on their own. So, health professionals should be proactive during routine consultations and not hesitate to ask their patients of menopausal age if they have certain symptoms, suggest Drs. Jarcevic and Bouteaud. This doesn't happen often enough; according to the survey, only a quarter of women indicated that their family doctor had started a conversation on the subject with them.“You could ask your patients if they have vasomotor symptoms, changes in their menstruation, vaginal symptoms, incontinence and ask them about their sleep and their mood,” suggested Dr. Jarcevic. If so, check with them to see if their symptoms are bothersome before considering treatment.But before concluding that it is menopause, also make sure there are no other causes that could explain the symptoms, particularly for mood or sleep disorders.Dr. Jarcevic recommends the website MQ6.ca, a decision support tool for menopause management that offers a symptom screening questionnaire that can help health professionals get the conversation going.Prescribe hormone therapy as first-line treatmentDr. Bouteaud points out that hormone therapy should be the first-line treatment to reduce menopausal symptoms if there are no contraindications, such as a personal history of hormone-dependent cancer. “Unless the patient prefers non-hormonal treatment or there is a contraindication, non-hormonal treatments should not be prescribed before hormonal therapy, because the literature shows that they are much less effective,” she explained. "Not all women are candidates for hormone therapy, but there are certainly more who could benefit from it than we currently see.”The MQ6.ca website also offers a decision tree, a list of contraindications and the different treatments available with the suggested dosage.Read: New menopause drug for hot flashes gets U.S. FDA approvalEnsure adequate followupThe patient should experience an improvement in menopausal symptoms within two weeks of starting hormone therapy, said Dr. Jarcevic. He suggests following up in three to four months to adjust if symptoms persist or if side-effects occur. “The most common side-effect is the presence of bleeding, which is also the main cause of discontinuation of hormonal therapy,” he said. The patient could also complain of breast pain, bloating, nausea and headaches, but these side effects usually resolve.After this first followup, if the symptoms of menopause are well controlled, annual followup or every two years is usually sufficient. He adds that there is a myth that hormone therapy cannot be taken for more than five years. "It's wrong. There is no real limit,” said Dr. Jarcevic.Know when to call a specialist"We want health professionals to feel comfortable and able to prescribe first-line treatment to patients without contraindications and who are not complex cases,” says Dr. Bouteaud. However, some cases may require consultation with a specialist. Appropriate cases could include if the patient has a complex health problem, significant adverse effects or remains very symptomatic despite treatment.“Waiting times for consultation with a gynecologist can, however, be quite long. Sometimes, a telephone call . . . with a gynecologist is enough. Try to call a specialist, if possible, before systematically referring the patient, so that she does not have to wait 18 months to be treated,” suggests the gynecologist.Read: Have you had the HRT talk yet? New review says docs should pipe up more about menopause symptoms and treatmentsDo not hesitate to combine systemic therapy with vaginal therapyIt is a myth that systemic and vaginal/local therapies cannot be combined, both doctors noted. “Systemic treatments may not resolve the problems of genitourinary syndrome of menopause, so do not hesitate to combine them with local treatments,” said Dr. Bouteaud. She added that local treatments are underused even though they are easy to prescribe and safe, since the only contraindication is the presence of undiagnosed vaginal bleeding.Reassure patients by presenting them with factsSome patients may be reluctant to take hormones, due to fears or preconceived ideas, noted Dr. Bouteaud. According to her, the best way to reassure worried patients is to simply present the facts. “One of the main fears shared by patients is that hormone therapy increases the risk of breast cancer. Data from the WHI study show that systemic hormone therapy with synthetic molecules (conjugated equine estrogens and medroxyprogesterone acetate) causes less than one additional case of breast cancer per 1,000 women (8/10,000 women), for example.” Dr. Jarcevic also recommends presenting the benefits of hormonal therapy, particularly on cardiovascular health, bone health or even explaining how the treatment can improve patient quality of life. Doctors indicate, however, that despite this, some patients will never agree to take hormonal therapy and that their choice must be respected.Update your knowledgeKnowledge about hormone therapy as well as available products have changed over the past 20 years, noted Dr. Bouteaud. “If your latest knowledge or training on the subject was more than 20 years ago, it's worth getting a modern, current update,” she said. The Association of Obstetricians-Gynecologists of Quebec (AOGQ) will, for example, offer training on menopause intended for health professionals in March 2024.

Five tips to help you prescribe first-line hormone therapy with confidence

Register for free access or login.

Related Topics