A

¨      HRT (both unopposed estrogen and combined estrogen progestogen therapy) is an effective treatment for hot flushes

¨      Tibolone is effective for alleviating the severity and reducing the frequency of hot flushes but is not currently available in NZ

B

¨      Unopposed estrogen therapy may be effective for reducing the waking episodes that are associated with sleep disruption.

¨      There is limited randomized evidence of efficacy for the following treatments:

-            Extracts prepared from black cohosh

-            Progesterone cream

-            Oral progestogen alone

¨      There is inconsistent randomized evidence of efficacy for the following treatments:

-         Phytoestrogen enriched food products or tablets

-         Clonidine

¨      There is no conclusive evidence that the following treatments relieve vasomotor symptoms:

-            Danazol

-           Ginseng

-           Dong quai

-           Vitamin E

-           Exercise

-           Relaxation

-           Behavioural therapy

¨      There is no evidence that HRT is effective for the specific treatment of other vasomotor symptoms such as headaches and dizziness.

A

¨      Low dose topical estrogen administered either in cream or tablet form or by means of an estradiol-releasing ring is an effective treatment for symptoms of vaginal atrophy.  For cream or tablets, the recommended regimen is daily for 3 to 4 weeks followed by once or twice a week.

¨      Low potency oral estrogen (estriol) therapy is also effective but requires either the addition of progestogen or close monitoring of the endometrium

¨      Tibolone has been shown to be effective for vaginal atrophy but is not currently available in NZ

B

¨      A vaginal moisturiser, Replens, (not currently available in NZ) is an effective non-hormonal treatment which may offer some relief from vaginal dryness

¨      Intravaginal estrogen therapy for 6-8 months results in reduced recurrence of UTIs in women susceptible to recurrent UTIs

¨      Oral estrogen is not effective for the prevention of recurrent UTIs.

There is insufficient or inconsistent evidence of benefit of oral or topical unopposed estrogen therapy for the treatment of urinary incontinence in postmenopausal women.

A

¨      Estrogen is not an effective treatment in elderly women with established Alzheimer’s disease (AD)(of mild to moderate severity).  It is unknown whether HRT has any benefits for younger postmenopausal women with AD.

¨      The addition of low doses of androgens to HRT provides relief in women with either a premature or surgical menopause who suffer from low libido.  The safety of this therapy has not been established for treatment continuing beyond 2 years.

¨      Tibolone is effective in providing relief from low libido in postmenopausal women but is not currently available in NZ.

¨      Estrogen replacement therapy is not an effective treatment for loss of libido in postmenopausal women.

D

¨      Combined estrogen-androgen therapy may be effective in postmenopausal women with a spontaneous menopause who complain of loss of libido.

There is insufficient or inconsistent evidence of benefit of HRT to justify the prescribing of HRT to:

¨      Improve measures of cognition

¨      prevent or delay the onset of Alzheimer’s disease

¨      elevate mood or relieve depression

There is insufficient or inconsistent evidence of benefit to justify the prescribing of HRT to:

¨      prevent skin aging

¨      reduce generalized body aches and pains

B

¨      Short term HRT use (<5 years) can be used, for appropriate indications, without increasing the risk of breast cancer diagnosis

¨      Longer-term use of HRT (>5 years) in postmenopausal women may be associated with an increase in risk of breast cancer diagnosis but it is uncertain whether mortality from breast cancer is affected.  For 1000 women commencing HRT at age 50, the excess numbers of breast cancers diagnosed would be 2 after 5 years of use, 6 after 10 years of use and 12 after 15 years of use.  This increased risk of breast cancer diagnosis disappears 5 years after HRT is discontinued.

C

¨      Cautious short term use (<5 years) of low dose HRT in localised breast cancer survivors may be considered if severe menopausal symptoms or low bone density are present and are unresponsive to other treatments

B

¨      HRT use is not associated with an increased risk of colorectal cancer.

A

¨      Unopposed estrogen therapy should not be used in women with a uterus because of an increased risk of endometrial cancer.

¨      Women who have had a hysterectomy may take unopposed estrogen therapy where this is indicated.

¨      Combined estrogen-progestogen therapy should be prescribed to women who have not had a hysterectomy and who want hormonal replacement for symptoms or prevention of osteoporosis.

¨      Combined continuous regimens offer better protection of the endometrium than sequential regimens.

B

¨      For combined continuous regimens, a minimum of 1mg norethisterone (NET), 2.5mg medroxyprogesterone acetate (MPA) or equivalent should be added to a moderate dose of estrogen.  For sequential regimens, 10 days or more of progestogen are required.

C

¨      Estrogen replacement for women who are endometrial cancer survivors (stage 1 or 2) can be considered if severe menopausal symptoms are present. 

A

¨      Previous ovarian cancer is not a contraindication for HRT

C

¨      There is no conclusive evidence that HRT either increases or decreases the risk of developing ovarian cancer.

A

¨      HRT has positive effects on bone density in postmenopausal women whether or not they have osteoporosis

¨      Bisphosphonates have comparable effectiveness to that of HRT in the treatment of osteoporosis and are an alternative treatment for osteoporosis in women who cannot use HRT

B

¨      Maintaining HRT use decreases the risk of vertebral fractures in women in the first decade after the surgical menopause.

¨      Maintaining HRT use decreases the risk of non-vertebral fractures in early postmenopausal women.

¨      Maintaining HRT use decreases the risk of vertebral fractures in women with established osteoporosis.

¨      Selective estrogen receptor modulators (SERMs) may be useful in the prevention of vertebral fractures in women who cannot use HRT or bisphosphonates.

B

¨      HRT is contraindicated for prevention of further coronary disease in women with established coronary artery disease because of lack of documented efficacy and a possible early excess mortality.

¨      Hypertension is not a contraindication for HRT but there is no evidence to support its use as an antihypertensive agent.

D

¨      There is insufficient evidence at present of benefit or harm from HRT for the primary prevention of coronary artery disease in menopausal or postmenopausal women.

¨      There is insufficient evidence at present of benefit or harm from HRT in the prevention of coronary artery disease following surgical menopause and there is no evidence of any cardiac benefit for women who have had an early natural menopause.

¨      There is presently no evidence that HRT, when given for non-cardiac reasons in women with established cardiac disease, needs to be discontinued if it has been used for 2 years or more, but the primary indication for prescribing HRT and the planned duration of treatment should be reviewed.

¨      In women with established coronary artery disease and osteoporosis, non-hormonal therapy with biphosphonates is recommended.

¨      There is no evidence that HRT is harmful when given to treat menopausal symptoms or for the prevention of osteoporosis in women who are at high risk of developing coronary artery disease but do not have established coronary artery disease.

C

¨      Women in atrial fibrillation taking HRT have a three-fold increased risk of ischaemic (non-haemorrhagic) stroke compared to women not taking HRT.

D

¨      There is no evidence to justify prescribing of HRT for the purposes of preventing stroke.

¨      Women in atrial fibrillation should be fully anticoagulated with warfarin before starting HRT.

¨      The safety of HRT therapy given to women who have suffered a previous stroke is not known.

B

¨      HRT increases the risk for idiopathic Venous Thromboembolism (VTE) three fold but the absolute risk in low risk women is low (9 - 11 cases/100,000 women per year in non users compared to 27 – 32 cases/100,000 women-years in users of HRT)

¨      The absolute risk rate for venous thromboembolism is higher in women with coronary artery disease (630/100,000 women-years) but this risk includes both idiopathic and nonidiopathic venous thromboembolic events (VTE).

¨      Raloxifene is associated with a similar increased risk of venous thromboembolism

¨      In women with known Coronary Artery Disease (CAD):

¨      The risk for venous thromboembolism is increased 18-fold for the first 90 days following a lower extremity fracture and 6-fold following hip fracture.  HRT should be withheld during this time ^;

¨     HRT should be withheld for 90 days following any surgery ^*

¨      HRT is contraindicated in women with a past history of venous thromboembolism.

D

¨      The risk for thromboembolic events is greatest in the first year of treatment.

¨      Assessment of individual thromboembolic risk including a past or family history of venous thromboembolism in first-degree relatives should be sought from all women before starting HRT.

¨      Where possible, HRT should be stopped at least 30 days prior to elective surgery ^.

¨      Women who have taken HRT therapy during the 30 days immediately prior to surgery should have routine thromboprophylaxis (TED)stockings and heparin/low molecular weight heparin) perioperatively.

¨      In women with known CAD< until evidence is available for these women, it is recommended that:

¨      HRT be withheld for 90 days following lower extremity or hip fracture and for 90 days following any surgery.

B

¨      HRT causes a small increased risk of gallstone formation (1 extra case per year per 250 estrogen users).

D

¨      Women with symptomatic gallstones should delay commencing HRT until after cholecystectomy.