Evolving issues in the clinical and managed care settings on the management of menopause following the women's health initiative.

Abstract

Publication of the Women's Health Initiative (WHI) trial results in 2002 significantly reduced physician and patient confidence in and acceptance of hormone replacement therapy (HRT) as an appropriate treatment option for menopause-associated vasomotor symptoms (VMS). This was true despite the fact that the WHI trial was a primary prevention study conducted in postmenopausal women and was not designed to evaluate the efficacy of HRT in the treatment of VMS. To review data from the WHI, including recent analyses, demonstrating the risks and benefits of HRT in postmenopausal women, to describe changes in menopause treatment guidelines and HRT use since publication of early WHI results nearly 6 years ago, and to identify opportunities for improving the quality of care in perimenopausal women. Early results from the WHI demonstrated that the risks of longterm HRT in postmenopausal women outweighed the benefits, leading study investigators to conclude that HRT should not be initiated or continued for the primary prevention of coronary heart disease (CHD) in postmenopausal women. Treatment guidelines published by several professional and managed care organizations continue to advocate the use of HRT for treatment of moderate-to-severe VMS. Nevertheless, physician and patient confidence in HRT has declined, as evidenced by a decrease in new HRT prescriptions and an increase in the discontinuation rate of HRT immediately following publication of the preliminary WHI results. Recent analyses demonstrate that the risk for CHD in postmenopausal women is largely dependent upon the age of the woman and the number of years since menopause, with a lower risk for CHD in women aged 50 to 59 years and in women who experienced menopause within the previous 10 years. The highest risk for CHD was evident in women aged 70 to 79 years and in women who experienced menopause 20 or more years ago. Although these data do not support the use of HRT as a primary prevention strategy in postmenopausal women, they do suggest the need to further evaluate the benefits and risks of HRT in perimenopausal women based on patient-specific characteristics, including age and time since menopause. Menopausal women present a unique opportunity for health care providers to improve the quality of care among women, not only as it relates to the treatment of VMS, but also as it relates to osteoporosis and cardiovascular disease, 2 common comorbidities in perimenopausal and postmenopausal women.