Insights from the Women's Health Initiative: individualizing risk assessment for hormone therapy decisions

Identifying appropriate candidates for menopausal hormone therapy (HT) is challenging given the complex profile of risks and benefits associated with treatment. Most professional societies agree that HT should not be used for chronic disease prevention. Recent findings from the Women's Health Initiative and other randomized trials suggest that a woman's age, proximity to menopause, underlying cardiovascular risk factor status, and various biological characteristics may modify health outcomes with HT. An emerging body of evidence suggests that it may be possible to assess individual risk and therefore better predict who is more likely to have favorable outcomes versus adverse effects when taking HT. Thus, once a woman is identified as a potential candidate for HT due to moderate-to-severe menopausal symptoms or other indications, risk stratification may be an important tool for minimizing patient risk. This individualized approach holds great promise for improving the safety of HT. We review here the evidence for this approach, focusing on vascular health because of limited data on other outcomes. The ultimate goal of this research is to develop a personalized risk/benefit prediction model to be used when a woman seeks therapy for symptom management. Patient centered outcomes including quality of life and sense of well-being should also be incorporated and will directly impact the benefit: risk ratio and compliance. Additional research on hormone dose, formulation, and route of delivery will be important for improving this model.