More menopause education urgently needed

Despite the availability of national and international guidelines setting out the evidence in favour of hormone replacement therapy, many menopausal women are still being denied potentially beneficial treatment

The menopause is a normal life event for women and so it is not an illness or a medical condition. As the life expectancy of women has increased over the past century this means that on average, women spend nearly one-third of their lives being postmenopausal. Many women suffer in silence and do not realise how effective hormone replacement therapy (HRT) can be at dramatically improving both their symptoms and also their quality of life.

It is estimated that around 75% of menopausal women experience symptoms, and around 25% of women experience severe symptoms that are having a negative effect on their lives, often affecting their family and work. The vasomotor symptoms of the menopause are the most obvious when thinking about the menopause, but these are not the symptoms that concern patients the most. It is the symptoms of low mood, anxiety, low self-esteem, poor memory and concentration, reduced libido and vaginal dryness that affect them the most.

Managing women with symptoms of the menopause is a very rewarding aspect of my job. I see hundreds of women in my clinic who have had symptoms for numerous years and have not received adequate support and treatment. There are now excellent guidelines available, both national and international, for healthcare professionals on the management of the menopause.^1-3

However, these guidelines have not been read by many healthcare professionals, which means that many women are being denied evidence-based treatment. All the guidelines support the notion that for the majority of women starting HRT when they are under 60 years old, the benefits of taking HRT usually outweigh any risks.

Many women are worried about the perceived risks of taking HRT and sadly many healthcare professionals are also worried – resulting in them too often refusing to give HRT to their patients.

Much of the negativity regarding HRT stems from the misinterpretation of the Women’s Health Initiative (WHI) study in 2002, which led to a worldwide reduction in confidence regarding HRT use.⁴ The results of this study were leaked to the press early, before they had been properly analysed. The subsequent sub-analysis of this study showed some really reassuring and positive results to support the use of HRT, especially in younger women.⁵

These results, in addition to results from other studies, have shown that shown that when HRT is given to women under the age of 60 years or within 10 years of menopause onset, it can reduce coronary heart disease and all-cause mortality.⁶ Many experts talk about a ‘timing hypothesis’ for postmenopausal hormone therapy, meaning that greatest benefits are gained from starting HRT early.

There are numerous potential benefits to be gained by women taking HRT. Symptoms of the menopause such as hot flushes, mood swings, night sweats, and reduced libido improve. In addition, taking HRT has also been shown to reduce future risk of osteoporosis, type 2 diabetes and osteoarthritis. It is really important that women are made aware of these benefits.

It is not just the timing of HRT that is important. The type of HRT also affects a woman’s risks and benefits. HRT containing micronised progesterone appears to be associated with a lower risk of breast cancer, cardiovascular disease, and thromboembolic events compared with androgenic progestogens.^7,8 Women who have had a hysterectomy and only require oestrogen have a lower risk of breast cancer compared with women taking combination HRT.

In addition, the mode of delivery of oestrogen is also important because, in contrast with oral oestrogen, transdermal oestrogen is not associated with an increased risk of venous thromboembolism.

Most women and many healthcare professionals are concerned about the possible risks of breast cancer in women taking HRT. However, the risk is far lower than many realise. Women who take oestrogen-only HRT (women who have had a hysterectomy) do not have a greater risk of breast cancer. Women who take oestrogen and a progestogen may have a small increased risk of breast cancer. However, this increased risk is a similar magnitude to the risk of breast cancer for women who are overweight or drinking a glass or two of wine each night. Telling women this often really helps to put this risk into perspective.

Clearly HRT is only one part of the management of perimenopausal and menopausal women. Lifestyle recommendations regarding diet, exercise, smoking cessation, and safe levels of alcohol consumption should be encouraged.

Many healthcare professionals have had very little training and education about the menopause and this needs to change. Menopause care needs to be mainly delivered in primary care, involving GPs, nurses and also pharmacists. Women need to receive an individualised consultation at all stages of diagnosis, investigation, and management of their menopause.

REFERENCES

1. National Institute for Health and Care Excellence. NICE guideline NG23 – Menopause: diagnosis and management 2015 [May 2017]. Available from: https://www.nice.org.uk/guidance/ng23

2. Baber RJ, Panay N, Fenton A, Group IMSW. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric 2016;19:109-50

3. Hamoda H, Panay N, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern 2016 recommendations on hormone replacement therapy in menopausal women. Post Reproductive Health 2016;22:165-83

4. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321-33

5. Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. JAMA. 2017; 318(10):927-938

6. Boardman HM, Hartley L, Eisinga A, et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev 2015:CD002229

7. Stute P, Wildt L, Neulen J. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018 Apr;21(2):111-122. M.

8. L’Hermite. Bioidentical menopausal hormone therapy: registered hormones (non-oral estradiol ± progesterone) are optimal. Climacteric 2017; 20:331-338