Primary prevention

The US Preventive Services Task Force (USPSTF) recommends against the use of hormone therapy (HT) for primary prevention of chronic conditions in postmenopausal women because the overall risks outweigh the benefits.[16] Potential primary prevention endpoints include a moderately decreased fracture risk, and a small decrease in the risk of developing diabetes or depression.[1]​​[17]​​​ These are more than offset by the increased risk of venous thromboembolism and a moderate increased risk of cardiovascular disease.​[18][19]​ In primary prevention trials, the risk of invasive breast cancer decreased with oestrogen-only treatment but increased in the combined oestrogen with progestin group. In particular, HT is not currently recommended for the primary prevention of cardiovascular disease.[17]​​[18][19][20] ​​​Further research is required to evaluate the impact of timing of HT initiation on coronary heart disease risk and mortality, but there may be some benefit if HT is started early (aged <60 years).[21]

Primary prevention must be made distinct from treatment of symptoms at the onset of menopause. For patients with significant symptoms, the benefits of therapy are likely to outweigh the risks.[17]

With greater awareness of the effect of declining oestrogen levels on cardiovascular and bone health, women should be advised about diet and lifestyle factors that can help to reduce early menopausal symptoms and improve later health. Such factors include maintaining healthy weight, smoking cessation, adequate calcium and vitamin D intake, increasing exercise, and reducing alcohol and caffeine.

In the absence of contraindications, HT is an effective therapeutic intervention for the prevention of osteoporosis in women under the age of 60 years and women within 10 years of menopause onset.[8][17]​​ Women with an intact uterus should receive combined oestrogen/progestin therapy to protect against endometrial hyperplasia and cancer, whereas women without a uterus should receive oestrogen alone.[8] There are no data to suggest greater efficacy of oral versus transdermal oestrogen; however, risk of venous thromboembolism may be lower with transdermal oestrogen due to the absence of the first-pass effect.[8][22][23][24]​ Younger women, particularly those <40 years, may require higher doses of HT than older women to effectively prevent against bone loss.[8] Benefit is maintained during treatment, but decreases once treatment stops.[1]​​[8] Upon stopping, the benefit of HT may persist for longer in women who took HT for longer.[1] Bisphosphonates may be appropriate to prevent bone loss in women with early menopause when oestrogen is contraindicated, or when HT is discontinued.[8] Regarding non-pharmacological interventions, regular low-intensity physical activity, such as walking, bowling, and golf, has been shown to lower hip fracture risk in postmenopausal women.[25]

Guidelines recommend systemic HT for women who undergo risk-reducing bilateral salpingo-oophorectomy before the natural menopause.[17]​​[26] A progestin is required if the uterus is preserved. HT may be continued until the time the natural menopause would have been expected; menopausal symptoms occurring when HT is stopped are managed in the same way as symptoms of natural menopause.[26]

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