RAMB Maio/Junho 2015

hormone

therapy

during

climacteric

for

all

ssoc

ras

2015; 61(3):191-192

191

EDITORIAL

Is hormone therapy during climacteric for all?

erapia

hormonal

climatério

para

todas

osé

aria

oares

únior

, I

sabel

C. E

spósito

orpreso

, E

dmund

C. B

aracat

Associate professor of Gynecology in the Department of Obstetrics and Gynecology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil

Associate professor of Gynecology in the Department of Obstetrics and Gynecology, HC-FMUSP, São Paulo, SP, Brazil

Full professor of Gynecology in the Department of Obstetrics and Gynecology, HC-FMUSP, São Paulo, SP

http://dx.doi.org/10.1590/1806-9282.61.03.191

Climacteric is a period of changes in women. It is the tran-

sition from childbearing years to a non-reproductive stage.

It is surrounded bymyths and fears. Etymologically, it means

critical time; it has, therefore, a negative connotation. Many

women do not experience symptoms or major difficulties

in this transition phase. But there is a group in which the

effect of estrogen deprivation is severe to the point of im-

pacting the quality of life and interpersonal, family and pro-

fessional relationships.

In general, these women complain

of severe vasomotor symptoms (hot flashes), which may in-

clude sweating and disrupt sleep when they happen over-

night.

For them, the best treatment is that with estrogen

therapy, but there are still restrictions on its use.

The debate over the use of hormone therapy in meno-

pause is old, from the 1963 feminist movement “Feminine

Forever” to the first reports of cases of endometrial and

breast cancer, culminating with the apocalyptic study

Women Health Initiative

(

WHI

), which showed negative ef-

fects, such as increased risk of cardiovascular disease and

breast cancer.

4,5

After this study, the prescription of hor-

mone therapy dropped worldwide,

including Brazil. Sev-

eral non-hormonal drugs have been tested with significant

reduction of hot flashes,

but with significant side effects

that prevented their use for longer periods of time. Thus,

researchers have begun to review the

WHI

, and other stud-

ies, to better understand the risk of cardiovascular disease

and its association with the use of hormone therapy.

After great reflection among societies studying cli-

macteric, the concept of window of opportunity for hor-

monal therapy (HT) was created. It corresponds to the

earliest time period to the start of HT. There is consen-

sus on the introduction of HT up to 10 years after meno-

pause, or until the age of 60 years.

7-9

After this time, it is

believed that endothelial dysfunction will be more ad-

vanced with established atheromatosis, preventing vaso-

dilation determined by nitric oxide, and facilitating plate-

let aggregation. There would also be an increase in

coagulation factors after the introduction of estrogen

therapy associated with progestogen.

It seems that the window of opportunity may explain,

in part, the concern for cardiovascular disease, but it does

not explain the unease about breast cancer with the use

of estroprogestative therapy. Perhaps one way to solve

this is to better assess the breast risk of these patients, es-

pecially in terms of family or personal history, when there

is ductal or lobular hyperplasia with atypia. In these cas-

es, thorough thinking must be given to whether to intro-

duce HT, or not. If necessary, employ lower doses in or-

der to reduce menopausal symptoms and, whenever

possible, use progestogens every three or four months to

prevent endometrial proliferation and the increased risk

of endometrial cancer. In women who have undergone

hysterectomy, this concern does not exist because, in gen-

eral, progestogen is not used.

It should be noted that if the patient already has car-

diovascular disease or any habit that increases cardiovas-

cular risk, such as smoking, drinking and sedentary life-

style, perhaps the window of opportunity has already been

lost, because the endothelial dysfunction may be more ad-

vanced. There is much discussion about whether the adop-

tion of healthy habits and elimination of addictions could

be an alternative to mitigate the risks, allowing the use of

hormonal therapy.

11,12

Despite being an alternative to its

use, prospective and well-controlled studies are insufficient

to state that this therapeutic modality is without risk.

Thus, hormone therapy should not be recommend-

ed for all climacteric women, as not all women experience

symptoms that interfere with their quality of life and oth-

ers have contraindications that prevent their use. Estro-

gen therapy is still the best way to suppress hot flashes

and increase urogenital tropism. Moreover, it assists in

reducing the risk of osteoporotic fracture. Dose and du-

ration of treatment should be individualized, though, and

discussed in each medical consultation. Many women

can benefit from estrogen therapy; not for the sake of be-

ing young forever, but to have good quality of life.

eferences

1. Galhardo CL, Soares JM Jr, Simões RS, Haidar MA, Rodrigues de Lima G,

Baracat EC. Estrogen effects on the vaginal pH, flora and cytology in late

postmenopause after a long period without hormone therapy. Clin Exp

Obstet Gynecol. 2006;33(2):85-9.