Benefits, Harms, and Costs
- 1Women who initiate menopausal hormone therapy shortly after menopause are, in general, at low risk for events in the next few years (high). Evidence supports aggressive identification and modification of risk factors as the most effective means of reducing cardiovascular risk (high).
- 2Women who initiate menopausal hormone therapy 10 or more years after menopause are at increased risk for adverse cardiac events (high).
- 3With respect to stroke, increased risk has been identified in all age groups using standard formulations of menopausal hormone therapy; however, the incidence in young women is extremely low (low).
- 4Incidence of venous thrombotic events increase with age (> 60 y) and BMI, even in otherwise healthy women; menopausal hormone therapy increases the risk (high).
- 5Menopausal hormone therapy is not indicated for primary or secondary prevention of cardiovascular disease (moderate).
- 6Women with premature or early-onset menopause appear to be at an increased risk of adverse cardiovascular outcomes, and this risk may be prevented by the use of menopausal hormone therapy until the average age of menopause (moderate).
- 7Menopausal hormone therapy increases the risk of venous thromboembolism; oral and combined hormone therapy preparations are more closely associated with risk of venous thromboembolism than either with transdermal preparations or estrogen alone (moderate).
- 8There is a lack of high-quality data to provide guidance on the impact of routes of estrogen administration on the risk of venous thrombotic events or cardiovascular disease (low).
- 1Menopausal hormone therapy should be offered as the most effective treatment for the relief of menopausal symptoms (strong, high).
- 2When prescribing menopausal hormone therapy, the lowest effective dose of estrogen, and, where indicated, estrogen-only therapy, should be offered to minimize the associated risk of venous thromboembolism (conditional, low).
- 3The lowest effective dose of estrogen, either oral or transdermal, should be prescribed to minimize the risk of stroke (conditional, low).
- 4When prescribing combined hormone therapy, choice of progestogen should favour those least likely to affect markers for cardiovascular disease. (strong, moderate).
- 5A tissue selective estrogen complex may be used without a progestin to provide menopausal hormone therapy and uterine protection for relief of early menopausal symptoms (conditional, moderate). To date, these agents do not appear to be associated with cardiovascular risk.
Abbreviations:CVD (cardiovascular disease), DOPS (Danish Osteoporosis Prevention Study), ELITE (Early Versus Late Intervention Trial With Estradiol), KEEPS (Kronos Early Estrogen Prevention Study), MHT (menopausal hormone therapy), SERM (selective estrogen receptor modulator), SMART (Selective estrogens, Menopause and Response to Therapy), VTE (venous thromboembolism), WHI (Women's Health Initiative)
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This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care providers. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that is evidence-based, culturally appropriate, and personalized.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women's health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person's needs.