Hormone therapy can work wonders in menopause but there are some things it cannot do.
Menopause seems to be the flavour of the month, especially with the current Senate inquiry into perimenopause and menopause.
It is heartening to see the interest in menopause and the calls for women and others experiencing menopause to have access to information and better health care.
Women with severe symptoms are still missing out on effective treatments in Australia, and sometimes this is because their GP just doesn’t offer menopausal hormone therapy when it is indicated. I hope that the ongoing work of women’s health organisations such as the Australasian Menopause Society (AMS), Jean Hailes and others enables more clinicians to be confident with MHT prescribing.
While discussion about menopause is welcome, along with it there has been an increase in concerning claims about menopause and MHT. These claims are presented on social media or in opinion pieces as mainstream expert opinion, but some of the claims are misleading. Let’s look at some of the claims being made.
Diagnosis of perimenopause based solely on symptoms
Some commentators are urging the diagnosis of perimenopause based on symptoms rather than on the internationally agreed criteria.
Perimenopause is defined as beginning when menstrual cycle changes occur as per the STRAW +10 criteria.
Not using agreed definitions of perimenopause leads to patient treatment with MHT outside of accepted indications.
To be clear, a woman with regular periods (in the absence of hormonal contraception) is not perimenopausal.
Indications for menopausal hormone therapy
Sometimes a long list of symptoms attributed to perimenopause and menopause is given, with the implication that MHT will help all of the symptoms.
However, many symptoms are non-specific and may be caused by other conditions.
While clusters of symptoms are more likely to be associated with menopause, it does not follow that MHT will fix all of them.
MHT is highly effective for vasomotor symptoms (hot flushes and night sweats) and may improve sleep disturbance, low mood or anxiety, low libido and genitourinary symptoms. It may help other symptoms such as musculoskeletal symptoms and fatigue but there is less evidence.
If perimenopause is to be diagnosed in women with regular periods who experience anxiety, fatigue, “brain fog” or other non-specific symptoms, this implies the potential prescription of MHT to vast numbers of women, often in their late 30s and early 40s.
Primary prevention of disease
We are seeing promotion of MHT for primary prevention of cardiovascular disease and dementia for women at the usual age of menopause. This is not supported by current guidelines.
There is ongoing debate about whether and to what extent MHT may reduce the risk of coronary heart disease when commenced early, but at this stage it is not recommended for this indication by heart authorities or menopause societies.
When it comes to dementia, there are some encouraging studies but there are also some studies that show an increase in risk associated with MHT. Again, guidelines advise that MHT should not be prescribed or promoted for dementia prevention.
Having said this, MHT has strong evidence for prevention of osteoporosis and fracture, and can be prescribed for this purpose for some women. It is a suitable option for some women under 65 with low bone density even in the absence of menopausal symptoms.
Testosterone
There is widespread promotion of testosterone as a routine component of MHT or for treatment of non-specific symptoms such as fatigue, low mood or “brain fog”.
The only current evidence-based indication for testosterone for cisgender women is hypoactive sexual desire dysfunction after menopause. Evidence for testosterone to treat any other symptom or for disease prevention is lacking.
Current inappropriate promotion of testosterone is resulting in women asking their GP for testosterone as the “missing piece of the puzzle”.
Breast cancer risk
Some commentators minimise the risks of MHT and make overly simplified statements regarding MHT use and breast cancer risk.
We can describe the risk associated with combined MHT as low and advise that oestrogen-only MHT (women with hysterectomy) confers little or no change in risk.
However, I would not advise Australian GPs to tell their patients that MHT is completely risk-free with respect to breast cancer.
Related
Contested evidence and the need for more research
Evidence is often contested in medicine, and this is very much the case when it comes to menopause. Cherry picking of data is common.
I can find you convincing studies that suggest that MHT prevents dementia, and equally compelling studies that suggest that MHT causes it.
Discussion about the merits of these studies is necessary and welcome. Guideline writers and expert bodies need to be challenged, but this must be done with the same academic rigour as for any other area of medicine.
There is a disappointing lack of research into many aspects of perimenopause and menopause.
For example, where are the long-term randomised placebo-controlled trials with transdermal oestrogen plus oral micronised progesterone investigating breast, heart and brain outcomes? When is MHT indicated as a treatment for mental health conditions?
Recommendations and practice outside of current guidelines
Guidelines and recommendations from expert bodies are just a starting point, and we should always consider the individual patient in front of us. GPs are accustomed to prescribing that does not strictly conform to guidelines when there is a good reason for their decision. And they may prescribe for an indication or patient group that is not in the TGA-approved product information from time to time.
But when we do this we need to have a clear rationale, including a diagnostic formulation. We need to consider the guidelines and evidence base, and if we are practice outside these, we should explain why to our patient.
Practitioners offering advice to colleagues need to be clear about what is mainstream medical advice and what is opinion. If they do not, it has the potential to cause confusion, especially for early-career doctors who may accept the advice as current best practice.
If clinicians find that in their experience MHT seems to help patients outside of accepted indications then they should be clear that this is anecdotal. It may well be that in future years there are expanded definitions of perimenopause and expanded indications for MHT, but we are not there yet.
There may be a significant number of women who develop various symptoms before perimenopause, and it’s reasonable to propose that some of these symptoms may be related to hormones.
Perhaps we need a new phase called pre-perimenopause (or peri-perimenopause as coined by a colleague!) And some of the symptoms may respond to treatment with oestrogen. But this has not yet been shown in trials. We can call for more research, but until we have solid evidence we need to be honest with our colleagues and our patients.
MHT is the most effective treatment for menopausal symptoms and has a role in preventing osteoporosis and fracture. It can be offered to women who are medically eligible, along with an individualised discussion of the benefits and risks.
AMS has released a statement this month discussing concerns about recent claims.
Where to seek information
I suggest clinicians scrutinise the evidence for the claims they hear, be sceptical of self-appointed experts and cautious in online discussions.
I encourage GPs and health professionals to seek information from guidelines and other resources produced or endorsed by national and international menopause bodies and recognised women’s health organisations.
- The 2023 Practitioner’s Toolkit for Managing Menopause has been endorsed by AMS, RANZCOG and other organisations.
- AMS provides a range of resources including a guide to MHT doses.
- Jean Hailes also provides education to clinicians and the general public.
- Other reliable information sources include the International Menopause Society and British Menopause Society.
Dr Karen Magraith is a GP and past president of the Australian Menopause Society.
