Table 1.

Recommendations for menopausal hormone therapy use in women with chronic diseases

Condition	Comments	Recommendations for HT
Obesity	While estrogen is not recommended for management of abdominal obesity, it is likely to result in favorable body composition changes. Progestogens with lower VTE risk and minimal effects on metabolic parameters are preferred.	Estrogen: Transdermal route of administration preferred Progestogen: Consider micronized progesterone, dydrogesterone or transdermal norethisterone
Hypertension	Current evidence does not support a deleterious effect of HT on BP in young postmenopausal normotensive or hypertensive women. Progestogens with beneficial or neutral BP effects preferred.	Estrogen: Transdermal route of administration preferred Progestogen: micronized progesterone, dydrogesterone, drospirenone
Dyslipidemia	Oral estrogen lowers LDL-C and increases HDL-C and TG; transdermal estrogen may lower total and LDL-C without significantly impacting HDL-C and TG.	Estrogen: Transdermal route of administration preferred in women with pre-existing hypertriglyceridemia, moderate CVD risk and in those with comorbidities including obesity, hypertension, and diabetes.
Diabetes	HT is associated with reduction in fasting glucose, insulin resistance and risk of T2DM. While oral estrogens may provide greater benefit in terms of improving insulin sensitivity versus transdermal routes of administration, transdermal is preferred given the more favorable effects on inflammatory markers, TG, and lower risk of VTE. Progestogens with minimal effects on glycemic control preferred.	Assess overall CVD risk and consider HT use in women with T2DM with bothersome symptoms who are not at high risk for CVD. Estrogen: Transdermal route of administration preferred, particularly in obese women and in those with moderate CVD risk. Progestogen: micronized progesterone, dydrogesterone, or transdermal norethisterone
Venous thromboembolism	Oral HT is associated with increased risk for VTE. Lower doses of oral estrogen may confer less risk than higher doses. Observational data show less risk with transdermal compared to oral estrogens. Safety data for low dose vaginal estrogens limited to 52 weeks; observational data have not shown increased risk for VTE. The type of progestogen likely also influences VTE risk. Other factors to consider: whether VTE was provoked, presence of inherited thrombophilia, obesity, malignancy, smoking, or immobility.	Non-hormonal treatment options preferred. Estrogen: If considered, use shared decision making that takes into account history, risk factors, menopause symptom severity, quality of life. Transdermal route of administration preferred if estrogen is used. Progestogen: micronized progesterone, dydrogesterone
Autoimmune disease	Some evidence suggests a link between autoimmune diseases and estrogen. It is unclear whether HT mitigates or reduces autoimmune disease incidence, risk or severity.	Individualize treatment and consider HT in symptomatic women with no contraindications to use. Avoid HT in women with antiphospholipid antibodies. Consider treating menopausal women with SS and vaginal dryness with low dose vaginal hormonal therapy.

HT=hormone therapy; VTE=venous thromboembolism; BP=blood pressure; LDL-C=low-density lipoprotein cholesterol; HDL-C=high-density lipoprotein cholesterol; TG=triglycerides; CVD=cardiovascular disease; T2DM=type 2 diabetes mellitus; SS=Sjogren’s syndrome