Stopping Menopausal Hormone Therapy (MHT): When and Why?

This morning the International Menopause Society presented on the consequences of stopping MHT, challenging existing beliefs that women should be taken off MHT after they reach the age of 60 or within 5 years of use. During their symposium, speakers Nick Panay, Rodney Barber and Mary Ann Lumsden highlighted the importance of making treatment duration personalised to the patient and explaining the real detail of study evidence that can often lead to misinformed decisions.

So what are the reasons for taking a patient off treatment? Currently decisions to discontinue are often influenced by recommendations, findings of recent studies, efficacy of treatment and adverse events. A range of factors can contribute to the stopping of MHT, with many women influenced by media coverage of links between MHT use and risk of cancer, strokes or mortality, however looking at the evidence IMS believe there is little data to mandate when MHT should be stopped:

  • Increased risk of Breast Cancer- The perceived increased risk of breast cancer as a result of MHT can be a reason many women decide to stop treatment. Some studies have shown that long term use of HRT with oestrogen and progestogen can lead to an increase in the risk of breast cancer however in the WHI study no increased risk of breast cancer was demonstrated by first time users of MHT. (1) The Nice Guidelines highlight that baseline risk changes for each woman and that any risk of breast cancer is related to treatment duration and reduces after stopping HRT. (2)
  • Increased risk of Ovarian Cancer- A meta-analysis performed by the Oxford Group (3) found that there was 1 additional case of ovarian cancer per 5000 women per year when MHT was used. However the significance of this data has been brought into question as data did not take into account dosage evaluation. The limited data available shows that any increase in risk of ovarian cancer with HRT is extremely small and mortality may even be decreased.
  • Increased risk of Strokes-WHI and Cochrane (4) follow-up studies show that MHT use increases risk of ischemic stroke after 60, but the data suggests the link is of questionable significance, more research is required to determine true risk.
  • Bone density- MHT has been linked to increase bone density, resulting in a lower risk of fracture.
  • Mortality- Most studies show a decrease in mortality with use of MHT. A recent Finnish study (5) highlighted 19 fewer CHD deaths and 7 fewer stroke deaths per 1,000 women using any HT for at least 10 years.
  • Vulvovaginal atrophy- after stopping MHT, any benefit in reduction of symptoms will be immediately lost
  • Impact on Quality of Life- Evidence that MHT improves overall quality of life is limited, although some studies have shown improvement in specific domains of MSQOL; sleep, sexual functioning, psychological and somatic symptoms, more research is needed to see if this can extend to general quality of life. A perceived negative impact on quality of life may be a reason patient’s continue on treatment.

After the decision to stop MHT is made, the method of stopping must be chosen. MHT can be stopped over time by reducing dose or numbers of day’s treatment is taken per week or alternatively can be stopped abruptly. NICE analysis shows that there is no benefit to tapering or stopping abruptly and the choice should be governed by patient preference.2

IMS believe the key is to personalise all decisions to the patient. They believe women should take MHT as long as they are experiencing treatment benefit and risks have been evaluated. Although current practice can be to stop MHT every 1-2 years, IMS believe evidence shows this is not necessary but instead importance should be placed on having a yearly evaluation with patients about whether treatment should be continued.

Do you agree with IMS’ belief we should be changing policy and training to reflect a new individualised approach to stopping MHT? Comment below we’d like to hear your thoughts!

References

1.       Chlebowski et al. “Menopausal hormone therapy and breast cancer mortality: clinical implications”, Ther Adv Drug Saf 2015, Vol. 6(2) 45–56.

2.       NICE guideline NG23. “Menopause: diagnosis and management”, Published November 2015.

3.       Greiser C.M et al. “Menopausal hormone therapy and risk of ovarian cancer: systematic review and meta-analysis”, Hum Reprod Update (2007) 13 (5): 453-463.

4.       Lager KE et al. “Healthcare interventions for reducing the risk of future stroke in people with previous stroke or transient ischaemic attack (TIA)”, Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009103.

5.       Mikkola et al. “Increased Cardiovascular Mortality Risk in Women Discontinuing Postmenopausal Hormone Therapy,” J Clin Endocrinol Metab (2015) 100 (12): 4588-4594.