Hot flashes, insomnia … The symptoms of menopause can be relieved by hormonal treatment: THM. In which cases is it prescribed? What is the difference with HRT? What are the contraindications? Update with Dr Isabelle Héron, president of the National Federation of Colleges of Medical Gynecology (FNCGM).
Definition: what is THM?
The menopause is a physiological phenomenon that occurs in all women, average age 50 years, ranging between 45 and 55 years. “It is important to distinguish between HRT and THM, “ warns Dr Isabelle Héron. THM (Menopause Hormonal Treatment) is prescribed to women who are menopausal at a normal age , around their fifties, to compensate for the lack of estrogen secretion by the ovaries at the time of menopause. As for HRT (Hormonal Replacement Therapy for Menopause), it concerns women with premature ovarian failure (formerly called “early menopause”), so it is a pathology.
Indications: for whom?
THM is not routinely given to postmenopausal women. It is recommended in two situations:
⇒ In women with severe climacteric syndrome leading to disabling symptoms such as: Hot flushes, sweating, Sleep disorders, vaginal dryness, arthralgia, irritability, nervousness, Depression.
⇒ In women with risk factors for increased osteoporosis.
“Hot flashes and sweating, when they are very debilitating, also impact sleep. Consequently, they can be responsible for an underlying depressive syndrome” , specifies the medical gynecologist.
At what age to prescribe it?
The prescription of THM depends on the age of onset of menopause, generally around 50 years old. A woman is said to have gone through menopause when she has had amenorrhea for at least a year.
“It seems that the risk of breast cancer, even if it is low, increases with the duration of the treatment, especially beyond 5 years of treatment”
What is its mode of action?
THM consists of providing the body with estrogen that is no longer produced by the ovaries. The administration of such a treatment requires a preliminary assessment to know the hormonal situation of the patient well and to judge the absence of contraindications.
In what form ?
THM includes natural estrogen, prescribed as a gel, patch, or tablet. The transcutaneous route is preferred, namely either the gel or the patch. “Estrogens are associated with natural progesterone to reduce the risk of endometrial pathology. In certain situations (hysterectomy), estrogen is prescribed alone”, indicates the president of the National Federation of Colleges of Medical Gynecology (FNCGM) .
What dosage?
The optimal dose is that which allows the troublesome symptoms to be controlled , knowing that the minimum dose is always required. 5 years remains the maximum recommended prescription period but a regular reassessment of the treatment, at least once a year, is necessary to reassess the benefit / risk balance: it is sometimes considered to interrupt the THM for a few weeks in order to ensure the persistence or decrease in the severity of the manifestations. When hormonal treatment for menopause is prescribed, it is essential to adopt a healthy lifestyle , the two pivotal elements of which are a balanced diet combined with regular physical activity.
What are the risks of THM?
► Breast cancer
“This is one of the most important points but also one of the most delicate to tackle because the results of the studies differ by the type of molecules used and the population studied”, concedes Dr Isabelle Héron. The large American WHI study, published in 2002, showed that hormonal treatment of menopause combining oral estrogen and synthetic progestins increased the risk of developing breast cancer compared to an untreated postmenopausal woman. “The French E3N study published a few years later did not show any increased risk of breast cancerwith natural estrogen prescribed transcutaneously and natural progesterone. It seems that the risk, even if it is low, increases with the duration of the treatment, in particular beyond 5 years of treatment “, continues the medical gynecologist. Hormonal treatment of menopause is formally contraindicated in cases of personal history of breast cancer.
► Phlebitis
Oral THM increases the risk of phlebitis and pulmonary embolism especially during the first year. This risk is not found with estrogen by the transcutaneous route.
► Arterial cardiovascular risk
This risk is currently being discussed because estrogen would have a protective role on healthy vessels. “Studies show that hormonal treatment of menopause leads to an increased risk of myocardial infarction and stroke, observes Dr Isabelle Héron. This risk is very low, it depends on the patient’s cardiovascular risk and exists especially when it is started late after the onset of menopause. It is therefore important to assess the level of cardiovascular risk of each patient before initiating an HRT. ”
What are the contraindications?
The main contraindications are:
- The estrogen-dependent cancers(breast cancer and endometrial cancer);
- The history of venous thrombosis(phlebitis) and arterial (myocardial infarction – stroke)
Other pathologies represent a contraindication to replacement therapy for menopause: Lupus , Otosclerosis, Porphyria, Chronic renal failure … “The doctor will always take into account the patient’s history to discuss the establishment of a hormonal treatment to ensure that it is not contraindicated, ” explains the specialist.
Precautions for use
“The decision of the THM involves the analysis of the patient’s benefit-risk balance , reassessed each year. This treatment has shown its effectiveness in improving the quality of life and in preventing osteoporosis. It is preferentially prescribed by the transcutaneous route, ” concludes the president of the National Federation of Colleges of Medical Gynecology (FNCGM).
