After much silent suffering and one giant setback, menopause medicine is helping women live the second half of their lives.
At the 19th World Congress on Menopause, the spotlight was firmly on the latest therapies and pharmaceutical advances, with new treatments eagerly showcased as the next frontier.
Yet, amid the buzz, leading experts reiterated an essential, evidence-backed message: menopausal hormone therapy remains the gold standard for alleviating the vast array of menopausal symptoms and preventing osteoporosis and perhaps cardiovascular disease.
Despite years of misconceptions rooted in the misinterpreted findings of the Women’s Health Initiative study – particularly around breast cancer risks – MHT’s efficacy and safety profile have been vindicated by subsequent research, proving it the most effective choice for women seeking relief and protection.
For Australian GPs, this is a powerful call to reconsider outdated fears and recognise MHT’s established benefits (a mission that Healthy Hormones champions by equipping practitioners with accessible, up-to-date menopause education they can trust).
MHT is safe
Professor Robert Langer, known for his tireless efforts to correct the 2002 WHI study, was a powerful presence at the conference (as well as being inundated by fans wanting a photograph). The WHI’s conclusions, which erroneously linked conjugated equine oestrogen (CEE) to breast cancer risk, has led to two decades of fear around MHT.
Professor Langer reiterated the breast safety of oestrogen, with long-term follow-up of WHI showing that women on CEE alone had a 23% reduced risk of breast cancer.
Professor John Eden presented a concise summary of the pathophysiology of breast cancer, explaining how the doubling time means that “the average ER+ PR+ breast cancer takes seven years to grow from one cell to 3mm”. The “initiation of cancer and then its progression are two different processes”, with “sex hormones, particularly progestins, being mild growth promoters”, not initiators. Factors including just being female, genetics, obesity and alcohol are all greater risk factors than use of MHT – an important message for our oncology colleagues who frequently blame MHT for causing a breast cancer.
With recent changes in Australian life insurance legislation, we may all be seeing more patients with BRCA. And given the low rate of MHT prescribing post-RRBSO (risk-reducing bilateral salpingo-oophorectomy), it was timely that Dr Howard Carp’s lecture reassured the audience of the safety of MHT (using oestrogen plus dydrogesterone or micronised progesterone) for these BRCA-positive previvors.
Disappointingly, no talk I attended answered the question of using MHT after breast cancer, although this was a question posed after several sessions.
The Australian Menopause Society and International Menopause Society experts I spoke to seemed confident in the safety of prescribing MHT after triple-negative breast cancer, and that women with a hormone-receptor-positive cancer also deserved a discussion.
This is certainly the area that needs urgent attention, as over 90% of women will survive their breast cancer, and many will develop symptoms and consequences of menopause.
The biggest losers
Professor Bronwyn Stuckey’s lecture on osteoporosis was packed with no-nonsense truths – her dry wit is legendary.
She reminded us that “all postmenopausal women are losers” when it comes to bone. Compared to “weapons-grade bone drugs” which too many young women are still prescribed first line, she described oestrogen as “nature’s gift”, with RCTs showing it is comparable to bisphosphonates and denosumab in preventing vertebral, non-vertebral and hip fractures. Not surprising, given its direct action on RANKL and osteoclasts.
And if you are anxious about waiting for 12-18 months to repeat a DEXA, monitoring bone turnover markers such as CTx can provide much earlier reassurance of MHT’s effect.
She emphasised that the IMS consensus was that there is “no mandatory age” for stopping MHT, introducing the idea to many attendees that MHT can be safe and beneficial even in older women.
This idea was further expounded by Professor Susan Davis, whose recent Lancet paper proposes no cutoff age even for initiating MHT (where appropriate). And unlike denosumab and bisphosphonates there is no risk of atypical femoral fracture or osteonecrosis of the jaw, nor rebound fracture risk if a woman does choose to stop her hormonal treatment.
The menopause blues
The connection between MHT and mental health was one of the most discussed themes of the conference. Data was presented showing the frequency and the severity with which women can experience this set of symptoms, affecting their ability to function including in the workplace.
Professor Claudio Soares reminded us randomised control trial data shows that oestradiol and micronised progesterone can both treat and prevent perimenopausal depression. Observational data from Newson Health shows that giving these hormones can reduce or even eliminate the need for antidepressants in perimenopausal women.
A new wave of psychologists and psychiatrists practicing hormone-focused medicine is an exciting development in the care of women’s mental health.
Professor Jayashri Kulkarni debated with Professor Pauline Maki on choosing MHT first line for perimenopausal depression. While the exercise was meant to stimulate discussion, the debate seemed to leave many attendees questioning MHT’s place as first-line therapy. We checked with Professor Maki afterwards and she conceded that she would recommend MHT if it was indeed perimenopausal depression.
Testing testosterone
We had two updates on testosterone therapy, including its applications and potential future uses. While testosterone is currently only licensed for HSDD (hypoactive sexual desire disorder), its therapeutic potential may extend beyond sexual health.
Professor Susan Davis summarised her team’s extensive research into the third female sex hormone. The only study that showed improvements with testosterone beyond HSDD was in immediate recall.
This certainly aligns with the patients who report they see a return of verbal fluency. Her team continue to work on several studies looking at possible benefits of testosterone in preventing heart failure, muscle and bone loss.
Professor James Simon presented an observational study showing improvements across multiple domains with the addition of testosterone to standard MHT. He detailed the many unknowns in the physiology of testosterone, but as Professor Simon aptly put it, “real doctors don’t always need to know how a drug works … just if it works.”
HRT to heart
The neglect of female-specific cardiovascular risk factors was highlighted by Professor Gemma Figtree.
This includes conditions in pregnancy (including hypertension, pre-eclampsia, IUGR and stillbirth, early loss of oestrogen (including POI and surgical menopause), as well as the misdiagnosis and mis- or under-treatment of women post cardiac event (lower rates of coronary angiography, total and timely revascularisation and PCI compared to men). And ultimately this results in women currently having a two-fold risk of death after acute coronary syndrome compared to men.
MHT’s role in cardiac health continues to evolve, with the consensus at IMS asserting a protective effect when initiated within 10 years of menopause onset, but as yet no move to recommend MHT as first line primary prevention for women experiencing menopause at the “normal” age of 45-55.
This is contrary to advice for women who experience premature (<40) or early (<45) menopause and POI (primary ovarian insufficiency) when the importance of using MHT as primary prevention of cardiovascular disease is not contested. This certainly makes one question what happens between 44 and 11 months and 45 and 1 month to support such a stance.
Oestrogen is known to exert positive effects such as increasing HDL cholesterol, improving insulin resistance and reducing atheroma formation. As Professor John Stevenson, who presented on MHT as primary prevention (with an unusual lack conflict of interest to declare), said “People are always trying to say that HRT isn’t that good, but I’m afraid that it is”.
Making women feel well
Dr Sylvia Rosevear, current president of the Australasian Menopause Society, showcased complex cases that illustrated the need for shared decision-making between patient and doctor.
Clearly a strong advocate for patient choice, as well as the appropriate use of MHT, she said there was nothing like it when you help “women just feel well”. Something many of us in menopause medicine will attest to.
I have not touched on the multiple presentations on GSM (genitourinary syndrome of menopause) because we know doctors continue to significantly underprescribe safe and effective vaginal hormones to the majority of post-menopausal women who have symptoms. And yet no presentations on why this should still be the case in 2024.
The IMS conference showcased the remarkable strides made in understanding the role of hormones in the brain, heart and bones. But the long shadow of WHI 2002 and the fear that oestrogen causes breast cancer remains for many, clinicians and women alike, with many novel treatments exploiting that fear.
We are 22 years on, and that link has been debunked, but bad news sticks.
We have a new wave of clinicians, looking for practical information to apply to real-world patients. Patients are educating themselves and their friends, and in the menopause space frequently finding they are more informed than their doctor.
This is what inspired us to create Healthy Hormones (please note the .au domain), an online community where members, both public and professional can share their experiences and ideas, ask questions of colleagues and access up-to-date evidence and resources.
With such collaboration and discussion as we have seen in our first five months, I honestly believe that we can change the landscape of women’s health.
Menopause is not just hot flushes, it is a pivotal point that determines how women, and those born with ovaries, will live the second half of their lives. And that makes menopause medicine possibly the best medicine of all.
Dr Ceri Cashell started her career in general practice in 2004 in Edinburgh but since 2012 she has been working in Avalon, Sydney, where she is a practice principal and owner. She is a passionate advocate for increased awareness of the effects of hormones on physical and mental health.
