Menopause: The Journal of The North American Menopause Society
Vol. 17, No. 2, pp. 242/255
* 2010 by The North American Menopause Society
Estrogen and progestogen use in postmenopausal women: 2010
position statement of The North American Menopause Society
Objective: To update for both clinicians and the lay public the evidence-based position statement published by
The North American Menopause Society (NAMS) in July 2008 regarding its recommendations for menopausal
hormone therapy (HT) for postmenopausal women, with consideration for the therapeutic benefit-risk ratio at
various times through menopause and beyond.
Methods: An Advisory Panel of clinicians and researchers expert in the field of women_s health was enlisted to
review the July 2008 NAMS position statement, evaluate new evidence through an evidence-based analysis, and
reach consensus on recommendations. The Panel_s recommendations were reviewed and approved by the NAMS
Board of Trustees as an official NAMS position statement. Also participating in the review process were other
interested organizations who then endorsed the document.
Results: Current evidence supports a consensus regarding the role of HT in postmenopausal women, when
potential therapeutic benefits and risks around the time of menopause are considered. This paper lists all these areas
along with explanatory comments. Areas that vary from the 2008 position statement are noted. A suggested reading
list of key references published since the last statement is also provided.
Conclusions: Recent data support the initiation of HT around the time of menopause to treat menopause-related
symptoms; to treat or reduce the risk of certain disorders, such as osteoporosis or fractures in select postmenopausal
women; or both. The benefit-risk ratio for menopausal HT is favorable for women who initiate HT close to
menopause but decreases in older women and with time since menopause in previously untreated women.
Key Words: Bioidentical hormones Y Breast cancer Y Cardiovascular disease Y Cognitive decline Y Coronary
heart disease Y Dementia Y Depression Y Diabetes mellitus Y Endometrial cancer Y Estrogen Y Estrogen progestogen
therapy Y Estrogen therapy Y Hormone replacement therapy Y Hormone therapy Y Menopause Y Mood Y NAMS Y
Osteoporosis Y Ovarian cancer Y Perimenopause Y Postmenopause Y Premature menopause Y Premature ovarian
insufficiency Y Progestogen Y Sexual function Y Stroke Y Total mortality Y Urinary health Y Quality of life Y Vaginal
atrophy Y Vaginal health Y Vasomotor symptoms Y Venous thromboembolism Y Women_s Health Initiative.
This NAMS position statement has been endorsed by:
Gynaecologists of Canada (SOGC)
1HealthyWomen (formerly the National Women_s Health
3Society of Obstetricians and
4The Endocrine Society,
6National Association of Nurse Practitioners in Women_s Health (NPWH).
2Asociacio ´n Mexicana para el Estudio del Climaterio (AMEC),
5American Medical Women_s Association (AMWA),
therapy (HT) in October 2002 (Menopause 2003;10:6-12),
September 2003 (Menopause 2003;10:497-506), October 2004
(Menopause 2004; 11:589-600), March 2007 (Menopause
2007;14:168-182), and July 2008 (Menopause 2008;15:584-
603). The goal of these position statements was to clarify the
benefit-risk ratio of HTVas either estrogen therapy (ET) or
combined estrogen-progestogen therapy (EPT)Vfor both
treatment of menopause-related symptoms and disease pre-
vention at various times through menopause and beyond.
he North American Menopause Society (NAMS), a
nonprofit scientific organization, published position
statements on the role of menopausal hormone
Received December 17, 2009; revised and accepted December 21, 2009.
The Board of Trustees of The North American Menopause Society
(NAMS) developed this position statement with assistance from the
following Advisory Panel: Wulf H. Utian, MD, PhD, DSc(Med), NCMP
(Chair); Gloria A. Bachmann, MD; Elizabeth Battaglino Cahill;1J.
Christopher Gallagher, MD; Francine Grodstein, ScD; Julia R. Heiman,
PhD, ABPP; Victor W. Henderson, MD, MS, NCMP; Howard N.
Hodis, MD; Richard H. Karas, MD, PhD; JoAnn E. Manson, MD,
DrPH; Julio H. Morfı ´n-Martı ´n, MD;2Robert L. Reid, MD;3Richard J.
Santen, MD;4Peter J. Schmidt, MD; Cynthia A. Stuenkel, MD, NCMP;
Norma Jo Waxman, MD;5and Susan Wysocki, WHNP-BC, FAANP.6
Approved by the NAMS Board of Trustees on December 16, 2009.
Address correspondence to: NAMS, 5900 Landerbrook Dr., Suite 390,
Mayfield Heights, OH 44124, USA. E-mail: firstname.lastname@example.org.
Web Site: www.menopause.org
Menopause, Vol. 17, No. 2, 2010
Because of the rapidly evolving data influencing the in-
teraction of the benefit-risk ratio of HT and clinical manage-
ment of aging women, the NAMS Board of Trustees
recognized the need to update its position statement. NAMS
convened a sixth Advisory Panel to provide recommenda-
tions and also place therapeutic benefits and risks into
perspective for both clinicians and the lay public. The op-
portunity was also taken to work in collaboration with The
Endocrine Society in their development of a detailed Sci-
entific Statement regarding the use of HT after menopause.
The Panel_s recommendations were reviewed and approved
by the 2009-2010 NAMS Board of Trustees.
The Society_s position statements provide expert analysis
of the totality of the data, including the most recent scientific
evidence, in an attempt to assist healthcare providers in their
practices and women in their decision making. These state-
ments do not represent codified practice standards as defined
by regulating bodies and insurance agencies.
An Advisory Panel of clinicians and researchers expert
in the field of women_s health was enlisted to review the
July 2008 NAMS position statement (available at http://
www.menopause.org/PSHT08.pdf), evaluate literature pub-
lished subsequent to the previous position statement, conduct
an evidence-based analysis, and attempt to reach consensus
on recommendations. New to the development process of the
2010 paper is the collaboration with other interested societies
that were invited to provide a representative to the NAMS HT
Panel; these societies are thus true endorsers of the recom-
mendations that follow. In addition, the Panel reviewed The
Endocrine Society’s Scientific Statement on postmenopausal
HT, which was in development.
A comprehensive literature search was conducted to
identify all relevant new publications that related ET or
EPT to menopause published subsequent to the 2008 position
statement (using the MeSH search terms Bioidentical
hormones, Breast cancer, Cardiovascular disease, Cognitive
decline, Coronary heart disease, Dementia, Depression,
Diabetes mellitus, Endometrial cancer, Estrogen, Estrogen-
progestogen therapy, Estrogen therapy, Hormone replace-
ment therapy, Hormone therapy, Lung cancer, Menopause,
Mood, NAMS, Osteoporosis, Ovarian cancer, Perimenopause,
Postmenopause, Premature menopause, Premature ovarian
insufficiency, Progestogen, Sexual function, Stroke, Total
mortality, Urinary health, Quality of life, Vaginal atrophy,
Vaginal health, Vasomotor symptoms, Venous thromboem-
bolism, and Women_s Health Initiative). Relevant papers were
also provided by the panelists. Limitations included a scarcity
of randomized prospective study data on the consequences of
long-term HT use when prescribed for symptom management
or disease risk-reduction. In addition, evidence-based medi-
cine implies that recommendations be limited to the women
for whom the studies are relevant. Although this goal is ideal
in principle, it is impossible in practice, given that there will
never be adequate randomized, controlled trials (RCTs) to
cover all populations, eventualities, drugs, and drug regimens.
The practice of medicine is ultimately based on the interpre-
tation at any one time of the entire body of available evidence.
NAMS recognizes that no trial data can be used to extrap-
olate clinical management recommendations for all women
and that no single trial should be used to make public health
recommendations. There are many observational studies but,
because the trials within the Women_s Health Initiative (WHI)
are for some outcomes the only large, relatively long-term
RCTs to date of postmenopausal women using HT, these
findings needed prominent consideration among all the studies
reviewed in the development of this paper. The Panel also
recognized that the WHI trials had several characteristics that
limit the ability to generalize the findings to all postmeno-
pausal women. These include the use of only one formulation
of estrogen (conjugated estrogens [CE]), alone or with one
progestin (medroxyprogesterone acetate [MPA]) and only one
route of administration (oral). Moreover, women studied in the
WHI were older (mean age, 63 y), mostly more than 10 years
beyond menopause and with more risk factors than younger
women whotypicallyuse HT,andlargelywithoutmenopause-
After considering all the evidence, the Panel provided its
recommendations, which were reviewed and approved by the
NAMS 2009-2010 Board of Trustees as an official NAMS
This position statement focuses on the use of HT products
available by prescription in the United States and Canada. A
current listing of these products is posted on the NAMS Web
aspx). This paper does not include other hormones, such as
selective estrogen-receptor modulators, those available with-
out a prescription (including phytoestrogens), and testosterone
therapy, the latter having been addressed in a previous NAMS
position statement (Menopause 2005;12:497-511).
The most current published references regarding HT are
found at the end of this statement.
NAMS strongly recommends the use of uniform and
consistent terminology when describing HT (see Table 1).
TABLE 1. NAMS menopausal hormone therapy terminology
& EPTVCombined estrogen-progestogen therapy
& ETVEstrogen therapy
& HTVHormone therapy (encompassing both ET and EPT)
& Local therapyVVaginal ET administration that does not result in clinically
significant systemic absorption
& ProgestogenVEncompassing both progesterone and progestin
& Systemic therapyVHT administration that results in absorption in the blood
high enough to provide clinically significant effects; in this paper, the terms
ET, EPT, HT, and progestogen are presented as systemic therapy unless
& Timing of HT initiationVLength of time after menopause when HT is
Menopause, Vol. 17, No. 2, 2010 243
NAMS POSITION STATEMENT
Publishing, Ferring, Novartis, Solvay, Wyeth; Speaker_s BureauV
Duramed, Novartis, Novo Nordisk, Wyeth.
For additional contributors not previously mentioned, Ms. Wisch
and Ms. Bilancini report no significant financial relationships.
The following list of suggested reading is restricted to literature
published since the previous position statement or pertinent to in-
formation added. For the full list of suggested reading published
before July 2008, see the NAMS Web site at http://www.menopause.
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Martin KA, Manson JE. Approach to the patient with menopausal symptoms.
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Quinn SD, Domoney C. The effects of hormones on urinary incontinence in
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Thurston RC, Sowers MR, Chang Y, et al. Adiposity and reporting of va-
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* 2010 The North American Menopause Society
NAMS POSITION STATEMENT
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