Menopause and hormone replacement therapy in women
with Rheumatic and Musculoskeletal Disease
The current recommendation of experts is to limit the use of hormonal replacement therapy (HRT) in healthy postmenopausal women and use the lowest dose enough to alleviate the symptoms.
According to studies, long-term HRT use show that risks, including breast cancer and stroke, outweigh the benefits.
Usually, the HRT type, dose, duration, timing, and administration may determine the risks that this type of therapy poses on women.
The benefit to risk balancing is going to be favourable for severe vasomotor symptoms in women who are 60 years old or over or within 10 years of the onset of menopause.
The North American Menopause Society said vasomator symptoms include hot flashes and night sweats.
Hot flashes are occurring from time to time as there are some transient occurrence of flushing, sweating and sensations ranging from warmth to intense heat usually occurring on the upper body and face. The heat sensation is sometimes followed by chills.
Moreover, the night sweats are actually hot flashes that happen as a woman sleeps.
The prevailing general contraindications to the use of HRT may include a history of breast cancer, coronary heart disease, past venous thromboembolic occurrence, stroke, or liver disease.
Experts strongly suggest the prudent use of HRT in postmenopausal women with rheumatic and musculoskeletal disease (RMD) without systemic lupus erymatosus (SLE) or positive antiphospholipid antibodies (aPL) who have severe vasomotor symptoms. The patient should have no contraindications with the use of HRT.
The use of HRT in symptomatic postmenopausal SLE patients could be a cause for concern due to the heightened risk of flare and/or thrombosis.
On the other hand, HRT use in aPL-negative women with quiescent SLE is something that can be considered.
SLE patients that don’t have positive aPL and want to get HRT as a way to alleviate vasomotor symptoms and at the same time have no contraindications, HRT use can be considered.
Current studies show that the use of oral HRT in aPL-negative women with SLE who have stable and low-level disease activity and no contraindication to use the HRT treatment is possible but in moderation.
There are no studies that have directly looked into the use of HRT in patients with moderate-to-high disease activity. The expert’s advice is that HRT use should be conditional due to a small risk involved that may give rise of lupus flares.
Furthermore, the estrogen use in aPL-positive patients is something that should be avoided because of the risk of thrombosis.
Current data are limited, for this reason, the specific recommendations for estrogen use in aPL-positive women could vary.
For females who are asymptomatic aPL, the experts more often conditionally recommend against the use of HRT.
HRT use in women with obstetric and/or thrombotic antiphospholipid syndrome (APS) should be strongly avoided.
Generally, experts and clinicians conditionally advice against using HRT in patients with APS who are getting anticoagulation treatment.
The same advice is given to patients with APS who are not positive for aPL.
Clinicians conditionally recommend HRT use for women with history of positive aPL but presently testing negative for aPL and have no history of clinical APS.
HRT may raise the risk of venous thrombosis (VTE) in the general population.
The types of estrogen and progestin and route of administration are factors that could affect risk.
Latest studies show that transdermal estrogen appears to be not pushing the rise of VTE risk in healthy women.
This is true even with women who have thrombotic mutations or may have a high body mass index.
There are no studies specifically assessing thrombosis risk with oral or transdermal HRT use in aPL-positive women.
The thrombosis risk is low in relation with HRT use in SLE patients with or without aPL.