Gonadal hormones and cognitive aging: a midlife perspective

Hormone therapy is associated with lower Alzheimer's disease tau biomarkers in post-menopausal females -evidence from two independent cohorts

BACKGROUND

Females represent approximately 70% of the Alzheimer's disease (AD) cases and the literature has proposed a connection between the decreased estrogen levels during menopause and an increased AD risk. Previous investigations have predominantly focused on assessing how hormone therapy (HT) affects the likelihood of AD development and cognitive deterioration. However, as the research framework has shifted toward a biomarker-defined AD and alterations in specific biomarkers could take place years before cognitive decline becomes discernible, it is crucial to examine how HT influences AD biomarkers. The main goal of this study was to evaluate the impact of HT on AD biomarker-informed pathophysiology in both cognitively unimpaired (CU) and cognitively impaired (CI) post-menopausal females across the aging and AD spectrum.

METHODS

This cross-sectional study included post-menopausal females without HT history (HT-) and with HT (HT+) at the time of PET imaging assessment from two cohorts: the Translational Biomarkers in Aging and Dementia (TRIAD) cohort, and the Alzheimer's Disease Neuroimaging Initiative (ADNI). Participants underwent magnetic resonance imaging (MRI), positron emission tomography (PET) and biofluid collection. Voxel-based t-tests were performed to assess the differences in amyloid-β (Aβ) and tau neurofibrillary tangles (NFTs) loads between HT- and HT + females. Linear regression models with interaction terms were also conducted to examine the interactive effects of HT and Aβ-PET on regional tau-PET.

RESULTS

HT + females demonstrated significantly lower tau-PET standardized uptake value ratio (SUVR) in Braak I-II ROIs (P < 0.05, Hedges' g = 0.73), Braak III-IV ROIs (P < 0.0001, Hedges' g = 0.74) and Braak V-VI ROIs (P < 0.0001, Hedges' g = 0.69) compared to HT- females. HT + females also showed significantly lower CSF p-tau181 (P < 0.001) and plasma p-tau181 (P < 0.0001) concentrations. Additionally, results from multivariate linear regression models indicated that HT interacts with cortical Aβ and is associated with lower regional NFT load.

CONCLUSIONS

Overall, findings from this observational study suggest that HT is associated with lower tau neuroimaging and fluid biomarkers in postmenopausal females. Due to the close link between tau and cognition, this study highlights the need for large randomized controlled trials designed to systemically study the influences of HT on AD biomarkers and disease progression.

Menopausal hormone therapy and risk of dementia: health insurance database in South Korea-based retrospective cohort study

Introduction

Menopausal hormone therapy (MHT) is used to alleviate the symptoms associated with menopause, despite the lack of recommendations for MHT in preventing dementia. Recent nationwide studies have explored the association between MHT and dementia risk, but the findings remain limited. This study aims to investigate the association between MHT and the incidence of Alzheimer's disease (AD) and non-AD dementia using national population data from Korea.

Methods

We conducted a retrospective study using data from the National Health Insurance Service in Korea between January 1, 2002, and December 31, 2019. Women over 40 years were eligible for this study and classified into the MHT or non-MHT groups. The MHT group consisted of women who used Tibolone (TIB), combined estrogen plus progestin by the manufacturer (CEPM), estrogen, combined estrogen plus progestin by a physician (CEPP), and transdermal estrogen during menopause. We compared the risk of dementia between the MHT and non-MHT groups.

Results

The study included 1,399,256 patients, of whom 387,477 were in the MHT group, and 1,011,779 were in the non-MHT group. The median duration of MHT was 23 months (range: 10-55 months). After adjusting for available confounders, we found that different types of MHT had varying effects on the occurrence of dementia. TIB (HR 1.041, 95% confidence interval (CI) 1.01-1.072) and oral estrogen alone (HR 1.081, 95% CI 1.03-1.134) were associated with a higher risk of AD dementia. In contrast, there was no difference in the risk of AD dementia by CEPM (HR 0.975, 95% CI 0.93-1.019), CEPP (HR 1.131, 95% CI 0.997-1.283), and transdermal estrogen (HR 0.989, 95% CI 0.757-1.292) use. The use of TIB, CEPM, and oral estrogen alone increased the risk of non-AD dementia (HR 1.335, 95% CI 1.303-1.368; HR 1.25, 95% CI 1.21-1.292; and HR 1.128, 95% CI 1.079-1.179; respectively), but there was no risk of non-AD dementia in the other MHT groups (CEPP and topical estrogen).

Conclusion

Our findings indicate that MHT has varying effects on the incidence of AD and non-AD dementia. Specifically, TIB, CEPM, and oral estrogen alone increase the risk of non-AD dementia, while transdermal estrogen is not associated with dementia risk. It is essential to consider the type of MHT used when assessing the risk of dementia in women.

Reproductive period duration and cognitive function in postmenopausal Latina women in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

OBJECTIVES

A shorter reproductive period, a marker of estrogen exposure, has been related to cognitive impairment among older (>65 years) non-Hispanic White women. We explored whether reproductive period duration, age at menarche, and age at menopause are related to cognitive function among postmenopausal Hispanic/Latina women.

METHODS

This cross-sectional analysis used baseline (Visit 1: 2008-2011) data from 3630 postmenopausal women in the Hispanic Community Health Study/Study of Latinos. Reproductive period duration, age at menarche, and age at menopause were assessed by self-report. Cognitive function variables included global cognition, verbal learning, memory, verbal fluency, and processing speed. Associations between each reproductive event and cognitive function were examined using multivariable linear and logistic regression analyses accounting for the complex survey design of the study and adjusting for socio-demographics, parity, and cardiovascular risk factors. We assessed whether associations differed by type of menopause (natural versus surgical) and hormone therapy use.

RESULTS

The study population was on average aged 59 years, with a mean reproductive period duration of 35 years. Older age at menopause and a longer reproductive period were related to higher verbal learning (β = 0.04, SE = 0.02; p < 0.05) and processing speed (ß = 0.16, SE = 0.04; p < 0.001); associations were more pronounced for women with natural menopause. Older age at menarche was associated with lower scores on the digit symbol substitution test (ß = -0.62, SE = 0.15; p < 0.0001). There were no associations with global cognition.

CONCLUSION

Among postmenopausal Hispanic/Latinas, a longer reproductive period was related to more favorable cognitive measures of verbal learning and processing speed. Our findings support the hypothesis that greater lifetime exposure to estrogens may be associated with higher cognitive performance.

Nicotinic acetylcholine receptors and learning and memory deficits in Neuroinflammatory diseases

Animal survival depends on cognitive abilities such as learning and memory to adapt to environmental changes. Memory functions require an enhanced activity and connectivity of a particular arrangement of engram neurons, supported by the concerted action of neurons, glia, and vascular cells. The deterioration of the cholinergic system is a common occurrence in neurological conditions exacerbated by aging such as traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), Alzheimer's disease (AD), and Parkinson's disease (PD). Cotinine is a cholinergic modulator with neuroprotective, antidepressant, anti-inflammatory, antioxidant, and memory-enhancing effects. Current evidence suggests Cotinine's beneficial effects on cognition results from the positive modulation of the α7-nicotinic acetylcholine receptors (nAChRs) and the inhibition of the toll-like receptors (TLRs). The α7nAChR affects brain functions by modulating the function of neurons, glia, endothelial, immune, and dendritic cells and regulates inhibitory and excitatory neurotransmission throughout the GABA interneurons. In addition, Cotinine acting on the α7 nAChRs and TLR reduces neuroinflammation by inhibiting the release of pro-inflammatory cytokines by the immune cells. Also, α7nAChRs stimulate signaling pathways supporting structural, biochemical, electrochemical, and cellular changes in the Central nervous system during the cognitive processes, including Neurogenesis. Here, the mechanisms of memory formation as well as potential mechanisms of action of Cotinine on memory preservation in aging and neurological diseases are discussed.

Review of menopausal hormone therapy with estradiol and progesterone versus other estrogens and progestins

Objective: The objective of the present document was to review/summarize reported outcomes compared between menopausal hormone therapy (MHT) containing estradiol (E2) versus other estrogens and MHT with progesterone (P4) versus progestins (defined as synthetic progestogens).Methods: PubMed and EMBASE were systematically searched through February 2021 for studies comparing oral E2 versus oral conjugated equine estrogens (CEE) or P4 versus progestins for endometrial outcomes, venous thromboembolism (VTE), cardiovascular outcomes, breast outcomes, cognition, and bone outcomes in postmenopausal women.Results: A total of 74 comparative publications were identified/summarized. Randomized studies suggested that P4 and progestins are likely equally effective in preventing endometrial hyperplasia/cancer when used at adequate doses. E2- versus CEE-based MHT had a similar or possibly better risk profile for VTE and cardiovascular outcomes, and P4- versus progestin-based MHT had a similar or possibly better profile for breast cancer and cardiovascular outcomes. E2 may potentially protect better against age-related cognitive decline and bone fractures versus CEE; P4 was similar or possibly better versus progestins for these outcomes. Limitations are that many studies were observational and some were not adequately powered for the reported outcomes.Conclusions: Evidence suggests a differential effect of MHT containing E2 or P4 and those containing CEE or progestins, with some evidence trending to a potentially better safety profile with E2 and/or P4.

The surgical menopause

Surgical menopause (iatrogenic menopause) happens when both ovaries are removed before the natural "switching off" of ovarian function; it can cause premature ovarian insufficiency where the menopause occurs in women before the age of 40. Surgical menopause is associated with a sudden reduction of ovarian sex steroid production rather than a gradual one as is the case in natural menopause. In women who have undergone bilateral salpingo-oophorectomy (BSO) before the natural age of menopause, strong consideration should be given to giving hormone replacement therapy (HRT) till the natural age of menopause at least. Sexual function and sexual desire are altered post-BSO, especially in younger women hence part of HRT prescription must include consideration of androgen too.

Sex differences in cognition and aging and the influence of sex hormones

Sex differences in cognitive functioning have been consistently reported in some cognitive tasks, with varying effect sizes. The most consistent findings in healthy adults are sex differences in the areas of mental rotation and aspects of attention and verbal memory. Sex differences in the vulnerability and manifestation of several psychiatric and neurologic diseases that involve cognitive disruption provide strong justification to continue investigating the social and biologic influences that underpin sex differences in cognitive functioning across health and disease. The biologic influences are thought to include genetic and epigenetic factors, sex chromosomes, and sex hormones. Sex steroid hormones that regulate reproductive function have multiple effects on the development, maintenance, and function of the brain, including significant effects on cognitive functioning. The aim of the current chapter is to provide a theoretical review of sex differences across different cognitive domains in adulthood and aging, as well as provide an overview on the role of sex hormones in cognitive function and cognitive decline.

Cognitive Changes with Reproductive Aging, Perimenopause, and Menopause

This article reviews the role of endogenous estrogen in neural and cognitive processing, followed by an examination of longitudinal cognitive data captured in various stages of the menopausal transition. The remaining text reviews the contradictory results from major hormone therapy trials to date, evidence for the "timing hypothesis," and closes with recommendations for future research and for practicing clinicians.

Sex Differences and the Influence of Sex Hormones on Cognition through Adulthood and the Aging Process

Hormones of the hypothalamic-pituitary-gonadal (HPG) axis that regulate reproductive function have multiple effects on the development, maintenance and function of the brain. Sex differences in cognitive functioning have been reported in both health and disease, which may be partly attributed to sex hormones. The aim of the current paper was to provide a theoretical review of how sex hormones influence cognitive functioning across the lifespan as well as provide an overview of the literature on sex differences and the role of sex hormones in cognitive decline, specifically in relation to Alzheimer’s disease (AD). A summary of current hormone and sex-based interventions for enhancing cognitive functioning and/or reducing the risk of Alzheimer’s disease is also provided.

Age at menopause and lifetime cognition: Findings from a British birth cohort study

OBJECTIVE

We investigated whether cognitive performance between ages 43 and 69 years was associated with timing of menopause, controlling for hormone replacement therapy, childhood cognitive ability, and sociobehavioral factors.

METHODS

We used data from 1,315 women participating in the Medical Research Council National Survey of Health and Development (a British birth cohort study) with known age at period cessation and up to 4 assessments of verbal memory (word-learning task) and processing speed (letter-cancellation task) at ages 43, 53, 60-64, and 69. We fitted multilevel models with linear and quadratic age terms, stratified by natural or surgical menopause, and adjusted for hormone replacement therapy, body mass index, smoking, occupational class, education, and childhood cognitive ability.

RESULTS

Verbal memory increased with later age at natural menopause (0.17 words per year, 95% confidence interval [CI]: 0.07-0.27, p = 0.001); an association remained, albeit attenuated, after full adjustment (0.09, 95% CI: 0.02-0.17, p = 0.013). Verbal memory also increased with later age at surgical menopause (0.16, 95% CI: 0.06-0.27, p = 0.002), but this association was fully attenuated after adjustment. Search speed was not associated with age at menopause.

CONCLUSION

Our findings suggest lifelong hormonal processes, not just short-term fluctuations during the menopause transition, may be associated with verbal memory, consistent with evidence from a variety of neurobiological studies; mechanisms are likely to involve estrogen receptor β function. Further follow-up is required to assess fully the clinical significance of these associations.

Hormone therapy at early post-menopause increases cognitive control-related prefrontal activity

Clinical data have been equivocal and controversial as to the benefits to the brain and cognition of hormone therapy (HT) in postmenopausal women. Recent reevaluation of the role of estrogens proposed that HT may effectively prevent the deleterious effects of aging on cognition, and reduces the risks of dementia, including Alzheimer's disease, if initiated early at the beginning of menopause. Yet, little is known about the effects of HT on brain activation related to cognitive control, the ability to make flexible decisions in relation to internal goals. Here, we used fMRI to directly test for a modulation of sequential 17β estradiol (2 mg/day) plus oral progesterone (100 mg/day) on task switching-related brain activity in women at early postmenopause. The results showed that HT enhanced dorsolateral prefrontal cortex recruitment during task switching. Between-subjects correlation analyses revealed that women who engaged more the dorsolateral prefrontal cortex showed higher task switching performance after HT administration. These results suggest that HT, when taken early at the beginning of postmenopause, may have beneficial effect on cognitive control prefrontal mechanisms. Together, these findings demonstrate that HT can prevent the appearance of reduced prefrontal cortex activity, a neurophysiological measure observed both in healthy aging and early dementia.

Evidence for Cognitive Aging in Midlife Women: Study of Women's Health Across the Nation

Although cross-sectional studies suggest that cognitive aging starts in midlife, few longitudinal studies have documented within-individual declines in cognitive performance before the seventh decade. Learning from repeat testing, or practice effects, can mask the decline in younger cohorts. In women, the menopause transition also affects test performance and can confound estimates of underlying decline. We designed this study to determine if, after controlling for practice effects, the menopause transition, and the symptoms associated with it, there is evidence of cognitive aging in midlife women. We used data from a longitudinal observational study in 2,124 participants from the Study of Women’s Health Across the Nation. Outcomes examined were scores on annual tests of processing speed, verbal episodic memory (immediate and delayed), and working memory. To reduce the impact of practice effects and of the menopause transition, we used the third cognition testing visit as the baseline. Average age at this baseline was 54 years, and the majority of the women were postmenopausal; half the cohort was 2 or more years beyond the final menstrual period. There were 7,185 cognition assessments with median follow-up time of 6.5 years. In mixed effects regression, adjusted for practice effects, retention, menopause symtoms (depressive, anxiety, vasomotor, and sleep disturbance), and covariates, scores on 2 of 4 cognition tests declined. Mean decline in cognitive speed was 0.28 per year (95% confidence interval [CI] 0.20 to 0.36) or 4.9% in 10 years, and mean decline in verbal episodic memory (delayed testing) was 0.02 per year (95% CI: 0.00 to 0.03) or 2% in 10 years. Our results provide strong, longitudinal evidence of cognitive aging in midlife women, with substantial within-woman declines in processing speed and memory. Further research is needed to identify factors that influence decline rates and to develop interventions that slow cognitive aging.

Cognitive Effects of Hormone Therapy Continuation or Discontinuation in a Sample of Women at Risk for Alzheimer Disease

OBJECTIVE

Use of estrogen-based hormone therapy (HT) as a protection from cognitive decline and Alzheimer disease (AD) is controversial, although cumulative data support HT use when initiated close to menopause onset with estrogen formulations containing 17β-estradiol preferable to conjugated equine estrogen formulations. Little is known regarding specific populations of women who may derive benefit from HT.

METHODS

Women with heightened risk for AD (aged 49-69), all of whom were taking HT for at least 1 year and most of whom initiated HT close to menopause onset, underwent cognitive assessment followed by randomization to continue or discontinue HT. Assessments were repeated at 2 years after randomization.

RESULTS

Women who continued HT performed better on cognitive domains composed of measures of verbal memory and combined attention, working memory, and processing speed measures. Women who used 17β-estradiol versus conjugated equine estrogen, whether randomized to continue or discontinue HT, showed better verbal memory performance at the 2-year follow-up assessment. An interaction was also found with HT randomization and family history of AD in a first-degree relative. All female offspring of patients with AD declined in verbal memory; however, women who continued HT declined less than women who discontinued HT. Women without a first-degree relative with AD showed verbal memory improvement (likely because of practice effects) with continuance and declined with discontinuance of HT.

CONCLUSION

Continuation of HT use appears to protect cognition in women with heightened risk for AD when initiated close to menopause onset.

Biological factors and age-dependence of primary motor cortex experimental plasticity

To evaluate whether the age-dependence of brain plasticity correlates with the levels of proteins involved in hormone and brain functions we executed a paired associative stimulation (PAS) protocol and blood tests. We measured the PAS-induced plasticity in the primary motor cortex. Blood levels of the brain-derived neurotrophic factor (BDNF), estradiol, the insulin-like growth factor (IGF)-1, the insulin-like growth factor binding protein (IGFBP)-3, progesterone, sex hormone-binding globulin (SHBG), testosterone, and the transforming growth factor beta 1 (TGF-β1) were determined in 15 healthy men and 20 healthy women. We observed an age-related reduction of PAS-induced plasticity in females that it is not present in males. In females, PAS-induced plasticity displayed a correlation with testosterone (p = 0.006) that became a trend after the adjustment for the age effect (p = 0.078). In males, IGF-1 showed a nominally significant correlation with the PAS-induced plasticity (p = 0.043). In conclusion, we observed that hormone blood levels (testosterone in females and IGF-1 in males) may be involved in the age-dependence of brain plasticity.

Selective review of age-related needs of women with schizophrenia

OBJECTIVE

Recognizing that needs differ between men and women with schizophrenia and that they vary over time, this review attempts to categorize the needs that are relevant to younger and to older women.

METHOD

This is a selective literature review focusing on topic areas the two authors determined to be most germane to women with schizophrenia. Articles were selected on the basis of currency, comprehensiveness, and study design. Particular attention was paid to the voices of the women themselves.

RESULTS

There is considerable overlap between the needs of younger and older women with schizophrenia, but as a general rule, younger women require preventive strategies to stop the escalation of illness while older women require recovery interventions to regain lost hopes and abilities.

CONCLUSIONS

There is clinical utility in cataloguing the needs of younger and older women with schizophrenia and conceptualizing interventions according to gender and age rather than viewing needed services along purely diagnostic lines.

Three midlife strategies to prevent cognitive impairment due to Alzheimer's disease

The slow, progressive accumulation of pathology characteristic of Alzheimer's disease is the principal determinant of cognitive decline leading to dementia. Risk-reduction strategies during midlife focus on raising the clinical threshold for the appearance of cognitive symptoms and on reducing the extent of Alzheimer pathology. Best available evidence suggests an approach based on three, conceptually distinct strategies. (1) Raise the threshold for cognitive symptoms by improving brain health. To achieve this goal, the tactic is to reduce cerebrovascular risks mediated by hypertension, diabetes, cigarette smoking, and hyperlipidemia. (2) Raise the threshold for cognitive symptoms by enhancing cognitive reserve. Here, tactics focus on mental stimulation associated with occupation, leisure activities and social engagement. (3) Reduce the burden of Alzheimer pathology. The most promising tactic toward this end is regular aerobic exercise. Tactics in support of strategies to reduce cognitive impairment due to Alzheimer pathology are not yet substantiated by robust, consistent clinical trial evidence. There is pressing need for well-designed pragmatic trials to provide stronger evidence on preventive strategies for late-life cognitive decline and dementia.

Prevention of diseases after menopause

Women may expect to spend more than a third of their lives after menopause. Beginning in the sixth decade, many chronic diseases will begin to emerge, which will affect both the quality and quantity of a woman's life. Thus, the onset of menopause heralds an opportunity for prevention strategies to improve the quality of life and enhance longevity. Obesity, metabolic syndrome and diabetes, cardiovascular disease, osteoporosis and osteoarthritis, cognitive decline, dementia and depression, and cancer are the major diseases of concern. Prevention strategies at menopause have to begin with screening and careful assessment for risk factors, which should also include molecular and genetic diagnostics, as these become available. Identification of certain risks will then allow directed therapy. Evidence-based prevention for the diseases noted above include lifestyle management, cessation of smoking, curtailing excessive alcohol consumption, a healthy diet and moderate exercise, as well as mentally stimulating activities. Although the most recent publications from the follow-up studies of the Women's Health Initiative do not recommend menopause hormonal therapy as a prevention strategy, these conclusions may not be fully valid for midlife women, on the basis of the existing data. For healthy women aged 50-59 years, estrogen therapy decreases coronary heart disease and all-cause mortality; this interpretation is entirely consistent with results from other randomized, controlled trials and observational studies. Thus. as part of a comprehensive strategy to prevent chronic disease after menopause, menopausal hormone therapy, particularly estrogen therapy may be considered as part of the armamentarium.

Prospective randomized trial to assess effects of continuing hormone therapy on cerebral function in postmenopausal women at risk for dementia

The objective of this study was to examine the effects of estrogen-based hormone therapy (HT) on regional cerebral metabolism in postmenopausal women (mean age = 58, SD = 5) at risk for development of dementia. The prospective clinical trial design included pre- and post-intervention neuroimaging of women randomized to continue (HT+) or discontinue (HT−) therapy following an average of 10 years of use. The primary outcome measure was change in brain metabolism during the subsequent two years, as assessed with fluorodeoxyglucose-18 positron emission tomography (FDG-PET). Longitudinal FDG-PET data were available for 45 study completers. Results showed that women randomized to continue HT experienced relative preservation of frontal and parietal cortical metabolism, compared with women randomized to discontinue HT. Women who discontinued 17-β estradiol (17βE)-based HT, as well as women who continued conjugated equine estrogen (CEE)-based HT, exhibited significant decline in metabolism of the precuneus/posterior cingulate cortical (PCC) area. Significant decline in PCC metabolism was additionally seen in women taking concurrent progestins (with either 17βE or CEE). Together, these findings suggest that among postmenopausal subjects at risk for developing dementia, regional cerebral cortical metabolism is relatively preserved for at least two years in women randomized to continue HT, compared with women randomized to discontinue HT. In addition, continuing unopposed 17βE therapy is associated specifically with preservation of metabolism in PCC, known to undergo the most significant decline in the earliest stages of Alzheimer's disease.

Trial Registration

ClinicalTrials.govNCT00097058

Estrogen and the prefrontal cortex: towards a new understanding of estrogen's effects on executive functions in the menopause transition

Midlife decline in cognition, specifically in areas of executive functioning, is a frequent concern for which menopausal women seek clinical intervention. The dependence of executive processes on prefrontal cortex function suggests estrogen effects on this brain region may be key in identifying the sources of this decline. Recent evidence from rodent, nonhuman primate, and human subject studies indicates the importance of considering interactions of estrogen with neurotransmitter systems, stress, genotype, and individual life events when determining the cognitive effects of menopause and estrogen therapy.

Androgens in women before and after the menopause and post bilateral oophorectomy: clinical effects and indications for testosterone therapy

In postmenopausal women, the ovaries produce significant amounts of androgens for many years after the menopause. Bilateral oophorectomy markedly reduces circulating testosterone (T) in both pre- and postmenopausal women. Oral estrogen therapy in postmenopausal women increases sex hormone-binding globulin and decreases T bioavailablity. Circulating androgens decrease with increasing age. The occurrence of an androgen deficiency syndrome associated with loss of libido and sense of well-being is disputed, but in several randomized controlled trials, transdermal T patches produced a significant improvement in hypoactive sexual desire disorder in postmenopausal women who had bilateral oophorectomy and in some women who had a natural menopause. T therapy is legitimate and is clinically indicated in such women. T therapy may have other benefits in postmenopausal women including an increase in lean body mass and bone mineral density. T therapy should become an integral part of hormone therapy in selected postmenopausal women in the future.

The 2012 hormone therapy position statement of: The North American Menopause Society

OBJECTIVE

This position statement aimed to update the evidence-based position statement published by The North American Menopause Society (NAMS) in 2010 regarding recommendations for hormone therapy (HT) for postmenopausal women. This updated position statement further distinguishes the emerging differences in the therapeutic benefit-risk ratio between estrogen therapy (ET) and combined estrogen-progestogen therapy (EPT) at various ages and time intervals since menopause onset.

METHODS

An Advisory Panel of expert clinicians and researchers in the field of women's health was enlisted to review the 2010 NAMS position statement, evaluate new evidence, and reach consensus on recommendations. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees as an official NAMS position statement.

RESULTS

Current evidence supports the use of HT for perimenopausal and postmenopausal women when the balance of potential benefits and risks is favorable for the individual woman. This position statement reviews the effects of ET and EPT on many aspects of women's health and recognizes the greater safety profile associated with ET.

CONCLUSIONS

Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms and to prevent osteoporosis in women at high risk of fracture. The more favorable benefit-risk ratio for ET allows more flexibility in extending the duration of use compared with EPT, where the earlier appearance of increased breast cancer risk precludes a recommendation for use beyond 3 to 5 years.