A modern look at menopausal hormone therapy

News 04/02/2021

Menopause is the last independent menstruation in a woman's life, due to the hormonal function of the ovaries against the background of age-related changes.

In other words, it is a transitional state between the reproductive period and aging. The decrease in hormone levels occurs gradually after 40 years. First, the level of progesterone decreases, and then the level of estrogens. The menstrual cycle may be disrupted in the direction of shortening the cycle with subsequent delays of up to 2-3 months or more. Menopause is set after the absence of a menstrual cycle for 12 months.

Symptoms and clinical signs

Vasomotor systems	hot flashes increased sweating headaches arterial hypertension, chills rapid heartbeat
Emotional and mental disorders	irritability sleep disorder inattention decreased libido
Urogenital	vaginal dryness frequent urination urinary incontinence
Other	osteoporosis cardiovascular diseases weight gain hair loss

Hot flashes and night sweats are usually attributed to fast-passing and non-life-threatening signs. Most women inevitably go through this during the transition period and in the early postmenopause due to changes in the content of sex hormones.

The risk of developing cardiovascular diseases is increased by 51% in the group of women with frequent hot flashes than in the group of "asymptomatic" patients.

Despite the fears of cancer when prescribing menopausal hormone therapy (MHT), according to an expert assessment, in the United States, one in two women dies from heart disease or stroke, and only one in 25-from breast cancer. Malignant tumors of the mammary glands account for 3-5% of all breast formations. All the rest are benign diseases that are not a contraindication to the appointment of MGT.

The risk of breast cancer increases, starting with the 8-10-year duration of MGT use.

The goal of MHT is to partially compensate for the reduced ovarian function in the case of sex hormone deficiency, using such minimally optimal doses of hormonal drugs that would actually improve the general condition of patients, provide prevention of late metabolic disorders and would not be accompanied by side effects.

The basis for the appointment of MGT:

1. Individualization, i.e. the selection of drugs taking into account the state of the woman's health and concomitant diseases.
2. Assessment of the risk factors of a particular woman.
3. Personal preferences.
4. MGT goals.

Before prescribing therapy, a careful assessment of the benefit/risk balance is performed, with an emphasis on the role of MGT on: bone tissue, cardiovascular and central nervous systems, as well as genitourinary symptoms.

Additional positive effects of MGT:

• The incidence of colorectal cancer (CRC) is reduced in women on the background of MHT by 30%, so the appointment of its patients with a history of CRC has long been the world standard.
• The use of MGT reduces the risk of lung cancer.
• MGT is a first-line therapy for the prevention of osteoporosis and fractures in women with an increased risk of postmenopausal fractures under the age of 60 and/or menopause lasting up to 10 years.
• Promotes the preservation of the quality of bone and intervertebral discs in postmenopausal women:

- reduction of the risk of common fractures by 23%;

- hip fractures by 34%.

• Reducing the risk of diabetes mellitus (DM), and with existing DM – on the background of MGT, there is a decrease in fasting glucose and the HOMA-IR insulin resistance index.
• At the beginning of MHT in perimenopause, the risk of developing cardiovascular diseases decreases.

Examination before the appointment of MGT

In order to determine the possibility of using menopausal hormone therapy, the optimal forms and doses, it is necessary to undergo a specialist examination, which includes the following stages::

1. Collection of anamnesis (including family history of thrombosis, breast cancer).
2. Gynecological examination and examination of the mammary glands.
3. Cytological examination of smears (PAP test);
4. Transvaginal ultrasound of the pelvic organs.
5. Mammography.
6. Blood tests.
7. Densitometry of the lumbar spine and proximal femur.

Contraindications to MGT

Menopausal hormone therapy has a list of absolute and relative contraindications that a specialist should definitely take into account.

Absolute values:	Relative values:
bleeding from the genital tract of unknown origin; breast and endometrial cancer; acute hepatitis; acute deep vein thrombosis; allergy to MGT ingredients; skin porphyria.	uterine fibroids; endometriosis; migraine; venous thrombosis and embolism (history); gallstone disease; ovarian cancer (history).

In MHT, an annual reassessment of therapy is necessary, including analysis of concomitant pathology and periodic attempts to reduce the dose, including in the form of switching to potentially safe transdermal routes of low-dose administration or discontinuation of hormone therapy in general.

Timely prescribed MGT, taking into account the age of the woman, the duration of menopause, personal and family history data, can reduce the frequency of unpleasant symptoms and improve the quality of life.

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