My patient experienced menopause at 52 years. She had some menopausal symptoms – mainly hot flushes – but thought she would get over them. However, they are worsening and she is now experiencing joint pain, hair thinning and brain fog. Previously, she worried about the breast cancer issues discussed around MHT.
She is currently on no medications and her bloodwork is good. She does have insulin resistance and her BMI is in the overweight range. She is also seeing a breast surgeon for a benign breast lesion (her mother’s sister had breast cancer). I have asked for their opinion regarding MHT.
As she is eight years post menopause, should I commence her on MHT? I know technically MHT is considered appropriate to prescribe up to 10 years post menopause but she is in her 60s. If yes what do I need to be careful about beside cardiac risks? If I do prescribe MHT I will use gel/path + micronised progesterone. I am also intending to get a TVUS and discuss risks and benefits.
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From Jean Hailes Endocrinologist Dr Sonia Davison.
With regard to a trial of hormone therapy (MHT), it’s always a matter of weighing up the benefits and risks, and both you as the prescriber and the patient need to be happy with the decision. An evidence-based guide to the pros and cons of MHT can be found here.
Your patient’s excess weight and family history of breast cancer increase her risk of developing breast cancer. Ideally she would work on reducing her weight – this will help the insulin resistance and may also help reduce the flushes by decreasing effective body ‘insulation’. It should also reduce her cardiovascular risk.
If flushes are the main problem, it’s worth a trial of an SNRI or SSRI, starting at a low dose, as this may be sufficient for vasomotor symptom control.
If prescribing MHT, I would start with the lowest dose oestradiol, and the studies suggest that using micronised progesterone is associated with the lowest risk of breast cancer, compared with more androgenic progestogens.
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