Hormone Replacement Therapy for Menopause: When It's Indicated and Who Can Undergo Treatment

Approximately 17 million Brazilian women are experiencing climacteric, the transitional phase between reproductive and non-reproductive periods marked by a decline in estrogen and progesterone production. This hormonal reduction can lead to symptoms impacting quality of life, such as hot flashes, sleep disturbances, mood swings, and vaginal dryness. Despite effective hormone replacement therapy (HRT) being available, many women avoid or delay treatment due to fears about risks or lack of information. Gynecologist Maria Celeste Osório emphasizes that HRT remains the most effective treatment for climacteric and menopausal symptoms when properly indicated. She notes that the associated increased risk of breast cancer is very low (0.08%) and must be assessed within each patient's clinical context. Climacteric refers to the entire transition period, while menopause signifies the date of the last menstrual period. Symptoms can emerge years before the last period, with menstrual irregularities often being the first sign. Other common symptoms include night sweats, irritability, anxiety, vaginal dryness, painful intercourse, and urinary issues. The diagnosis is primarily clinical, based on patient history and symptoms, as hormonal tests can be unreliable due to significant fluctuations during this phase. HRT is most beneficial when initiated during the menopausal transition, within ten years after menopause, or before age 60, maximizing benefits and minimizing risks. While past studies raised concerns about breast cancer and cardiovascular risks, subsequent research indicates a very small increase in breast cancer risk, comparable to daily alcohol consumption or obesity. Treatment decisions consider age, symptom severity, time since menopause, and individual health risks. HRT can be administered orally, via patches, gels, or sprays, with non-oral routes often preferred for women with cardiovascular risks. Estrogen is the primary hormone used, with progesterone or progestogens added for women with a uterus. The Brazilian public health system (SUS) offers only local vaginal estriol treatment for genitourinary symptoms, lacking systemic options for broader climacteric symptoms. A new non-hormonal medication, fezolinetant (Veoza), has been approved in Brazil to treat hot flashes by acting on brain mechanisms, offering an alternative for women who cannot undergo HRT, including breast cancer patients. Current guidelines suggest no mandatory duration for HRT, with continuation decided individually based on sustained benefits and absence of adverse effects. Phytotherapy has limited evidence for symptom control, with insufficient scientific backing for consistent benefits, despite some individual reports of improvement.