Hormone therapy (HT) has generated much debate since a 2002 study reported cardiovascular and cancer risks, but more current and expanded research has led to a reconsideration of HT use in the general postmenopausal population and for those with rheumatic diseases.
On Sunday, two speakers reviewed much of that new evidence about the value of HT for patients with autoimmune disease during Menopausal Hormone Therapy in 2026: What Rheumatologists Need to Know. A recording of the session will be available to registered participants of ACR Convergence 2026 for on-demand viewing.
Stephanie Faubion, MD, MBA, Professor and Chair of the Department of Medicine at Mayo Clinic, Jacksonville, Florida, opened the session with a look at the patient factors that should guide the type, dosing, and duration of HT.
About a quarter of women in the United States used systemic HT in 2002 when risk concerns raised by the Women’s Health Initiative led to an approximately 80% decrease in use of this approach. As of a 2023 study, HT use still remained low despite expanded knowledge about the benefits and risks and better knowledge about who should use the therapy.
Women younger than 60 or less than 10 years post menopause are top candidates for HT, said Dr. Faubion, who is also Director at the Mayo Clinic Center for Women’s Health and Medical Director at The Menopause Society. Other important factors are patients with bothersome vasomotor, mood, and sleep problems, bone density concerns, and interest in using HT while having no excess risk of breast cancer or cardiovascular disease.
With systemic HT, Dr. Faubion said, the risks increase with age and also when estrogen and progesterone are combined compared with estrogen alone. But in the age 50 to 59 group, the most relevant group to consider for HT, she noted, there’s only a slightly increased risk of venous thromboembolism and pulmonary embolism. The estrogen-only group had a reduction in breast cancer rates, while the combination therapy group had a slight increase.
“Our vessels are getting older as we age, and these vessels develop disease as time goes by, so when a woman is perimenopausal and early postmenopausal, this is a time when estrogen may have the most benefit in terms of not causing issues for people as they get older,” Dr. Faubion said. “But if you put a postmenopausal woman who’s significantly past the menopause transition [on estrogen], she may already have vascular disease, and adding estrogen, especially oral estrogen, may increase the risk of heart attack and stroke.”
Dr. Faubion also addressed nonhormonal therapies available. Fezolinetant, approved by the U.S. Food and Drug Administration (FDA) in 2023, is an oral neurokinin 3 receptor antagonist that significantly reduced vasomotor symptoms. The most common adverse events reported were headaches, but fezolinetant does have a boxed warning for the potential for hepatotoxicity.
Elinzanetant, approved in 2025, is an oral neurokinin 1 and 3 receptor antagonist that reduced vasomotor frequency and severity while also improving sleep disturbances and menopause-related quality of life. The most common adverse events are headache, fatigue, and arthralgia, but no hepatotoxicity was reported.
Karen Costenbader, MD, MPH, Professor of Medicine at Harvard Medical School and the Michael Weinblatt, MD Distinguished Chair in Rheumatology, said that HT can be prescribed for patients with systemic lupus erythematosus (SLE) and other systemic autoimmune rheumatic diseases (SARDs) who are negative for both antiphospholipid syndrome (APS) and antiphospholipid (aPL), have stable disease, and have no contraindications.
Potential benefits include relief of the vasomotor symptoms of menopause, relief of vaginal dryness, and increased bone density.
“This can be confusing. You have a person come in, and they have aches and pains all over the place, and brain fog,” Dr. Costenbader said. “Is it their underlying rheumatic disease, or is it that they’re going through menopause? And how to sort those out? Sometimes we confuse this with fibromyalgia and depression as well.”
The main risks are a modest increase in mild-to-moderate SLE flares and—in women who are aPL-positive—thrombosis. Additional concerns are exacerbation of autoimmune disease, increased risk of cancer, increased risk of cardiovascular disease, and interactions with other medications.
Dr. Costenbader, who also serves as the Lupus Program Director at Brigham and Women’s Hospital, emphasized the shared decision-making aspects of deciding on HT. She said that the 2020 ACR Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases conditionally recommends HT in patients with SARDs when vasomotor symptoms are severe.
“We have to think: Is that the presenting problem? Does this patient have really severe vasomotor symptoms? There are no data yet on transdermal HT in antiphospholipid antibody patients or SARDs,” Dr. Costenbader said. “But for severe symptoms, low-dose transdermal HT is presumed to have lower thrombotic risk. Vaginal estrogen probably has little systemic absorption and helps with local symptoms.”
THERE’S STILL TIME TO JOIN US
If you haven’t registered for ACR Convergence 2026, you can still register on-site at the Orange County Convention Center in Orlando, Florida, through November 11. All registered participants receive on-demand access to scientific sessions through September 30, 2027.
