1. Date of download: 7/18/2016 Copyright © 2016 McGraw-Hill Education. All rights reserved. Chart for identifying appropriate candidates for postmenopausal hormone therapy (HT). CHD, coronary heart disease. a Reassess each step at least once every 6–12 months (assuming patient's continued preference for HT). bWomen who have vaginal dryness without moderate to severe vasomotor symptoms may be candidates for vaginal estrogen. c Traditional contraindications: unexplained vaginal bleeding; active liver disease; history of venous thromboembolism due to pregnancy, oral contraceptive use, or unknown etiology; blood clotting disorder; history of breast or endometrial cancer; history of CHD, stroke, transient ischemic attack, or diabetes. For other contraindications, including high triglycerides (>400 mg/dL); active gallbladder disease; and history of venous thromboembolism due to past immobility, surgery, or bone fracture; oral HT should be avoided but transdermal HT may be an option (see f below). d 10-year risk of CHD, based on Framingham Coronary Heart Disease Risk Score (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: JAMA 285:2486, 2001), as modified by JE Manson, with SS Bassuk: Hot Flashes, Hormones & Your Health. New York, McGraw-Hill, 2007. e Women >10 years past menopause are not good candidates for starting (first use of) HT. fAvoid oral HT. Transdermal HT may be an option because it has a less adverse effect on clotting factors, triglyceride levels, and inflammation factors than oral HT. g Consider selective serotonin or serotonin-norepinephrine reuptake inhibitor, gabapentin, clonidine, soy, or alternative. h HT should be continued only if moderate to severe menopausal symptoms persist. The recommended cutpoints for duration are based on results of the Women's Health Initiative estrogen-progestin and estrogen-alone trials, which lasted 5.6 and 7.1 years, respectively. For longer durations of HT use, balance of benefits and risks is not known. iAbove-average risk of breast cancer: one or more first-degree relatives with breast cancer; susceptibility genes such as BRCA1 or BRCA2; or a personal history of breast biopsy demonstrating atypia. jWomen with premature surgical menopause may take HT until average age at menopause (age 51 in the United States) and then follow flowchart for subsequent decision making. k If progestogen is taken daily, avoid extending duration. If progestogen is cyclical or infrequent, avoid extending duration more than 1–2 years. l If menopausal symptoms are severe, estrogen plus progestin can be taken for 2–3 years maximum and estrogen alone for 4–5 years maximum. mIf at high risk of osteoporotic fracture (see Q6), consider bisphosphonate, raloxifene, or alternative. n Increased risk of osteoporotic fracture: documented osteopenia, personal or family history of nontraumatic fracture, current smoking, or weight <125 lbs. Source: Adapted from JE Manson with SS Bassuk: Hot Flashes, Hormones & Your Health. New York, McGraw-Hill, 2007. Legend : From: Chapter 348. The Menopause Transition and Postmenopausal Hormone Therapy Harrison's Principles of Internal Medicine, 18e, 2012 From: Chapter 348. The Menopause Transition and Postmenopausal Hormone Therapy Harrison's Principles of Internal Medicine, 18e, 2012