The route decision in early and surgical menopause rests on other evidence

Agreement: I Agree Body: Dear Editor, Berggreen and colleagues provide contemporary estimates of thrombotic risk, and conclude that the method of use matters, without saying for whom the choice should change.¹ For the women who will take therapy longest, their cohort provides no direct evidence. Entry was restricted to women aged 50 to 69, a floor based on the average age of menopause. A history of oophorectomy, infertility treatment, endometriosis or polycystic ovary syndrome excluded women. Surgical menopause is therefore absent from the cohort, and age at menopause was never recorded, so early menopause cannot be separated within it. These are the women in whom systemic therapy matters most, and who start it earliest and continue it longest. The international premature ovarian insufficiency guideline states that hormone therapy can mitigate some of the consequences for bone, cardiovascular and cognitive health.² Joint FIGO and IMS guidance adds that early menopause should no longer be managed as a variant of menopause at the usual age.³ Guidance already favors transdermal over oral therapy for women at increased venous risk.⁴ Transdermal therapy was not associated with increased thrombotic rates in this cohort, and no separate estimate exists for either group. The reassurance therefore does not extend to early or surgical menopause. The same boundary shapes a second result, since the greatest arterial risk estimates appeared in women starting oral therapy before 50. Early menopause would be expected to cluster there, and surgical menopause was excluded. The authors note that menopausal history may partly explain the finding before 50, but not that these estimates cannot be applied to early or surgical menopause. Until that is examined, the route decision for these women rests on other evidence. Where the finding is quoted, its entry criteria should be quoted with it. References: 1. Berggreen J, Pourhadi N, Wood-Kurland H, et al. Contemporary menopausal hormone therapy and thrombotic disease: nationwide nested case-control study. BMJ 2026;394:e100688. 2. ESHRE, ASRM, CREWHIRL and IMS Guideline Group on POI, et al. Evidence-based guideline: Premature Ovarian Insufficiency. Fertil Steril 2025;123(2):221-36. 3. Benedetto C, Khadilkar SS, Nappi RE, et al. Hormone therapy (HT) in women with premature ovarian insufficiency or early menopause: time to think of a new paradigm for healthy aging. A joint FIGO and IMS position paper. Int J Gynaecol Obstet 2026;175(1):26-47. 4. National Institute for Health and Care Excellence. Menopause: identification and management. NICE guideline NG23. London: NICE, 2015 (updated November 2024). No competing Interests: Yes The following competing Interests: Electronic Publication Date: Tuesday, October 6, 2026 - 10:01 AI use: No, I have not used AI Highwire Comment Subject: Contemporary menopausal hormone therapy and thrombotic disease: nationwide nested case-control study Workflow State: Released Full Title: The route decision in early and surgical menopause rests on other evidence Highwire Comment Response to: Contemporary menopausal hormone therapy and thrombotic disease: nationwide nested case-control study Check this box if you would like your letter to appear anonymously:: Last Name: Zhang First name and middle initial: Jiawen Email: zhangjiawen@tongji.edu.cn Address: No. 301 Yan Chang Zhong Road, Shanghai, P.R.C. Occupation: Doctor Affiliation: Shanghai Tenth People's Hospital BMJ: Additional Article Info: Rapid response