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Best Practices for Menopausal Care - Is There Any Consensus?
Making sense of the information abyss
My Friends! The sea of information on how to manage the menopausal experience is vast and often confusing with media messaging that is all over the map. Three of the world's most reputable women's health societies have created position statements to help us make sense of it all. Their efforts are summarized here. Enjoy! Carla DiGirolamo, MD
One of the greatest challenges that mid-life women face is navigating the vast landscape of information on how to lead their best lives during menopause. The internet and social media have promoted widespread access to information. However, this has proven to be a double-edged sword.
The media frenzy surrounding the release of the Women’s Health Initiative was damaging because it invoked fear in menopausal women and their providers of using hormone therapy (HT) for the treatment of often debilitating menopausal symptoms. HT includes estrogens, progestogens, and in some cases, androgen (testosterone, DHEA) therapy. Societal stigmas and lack of study and understanding of the menopausal experience have created barriers for women seeking care or even just achieving a basic understanding of this stage of life. As a result, women have had difficulty receiving the care they need and providers have lacked resources upon which to base safe and effective care.
We have also seen the emergence of providers and services that promise “superior”, “safe” and easy access to hormonal products often involving expensive tests and the notion of the magic bullet for “curing” your “hormone deficiency” - this “disease” that we call “Menopause”. This is of particular concern in some geographies where there are shortages of hormonal treatment for menopausal symptoms, further feeding the desperation of some women.
In response to these challenges, some of the greatest minds in menopausal medicine have convened to objectively evaluate the scientific evidence and issue recommendations for providers and patients as a resource for safe and effective management of this stage of life where women will spend nearly half of their lives.
On June 9, 2022 the British Menopause Society (BMS) and the Royal College of Obstetricians and Gynaecologists (RCOG) issued a joint position statement on the best practices for the care of menopausal women. This statement - along with the North American Menopause Society 2017 position statement on hormone therapy - provides evidence-based recommendations based on a careful review of the peer-reviewed literature by experts in menopausal medicine who treat menopausal women every day.
Below is a summary of the key recommendations from the June 2022 BMS / RCOG Joint Position Statement and the 2017 NAMS Position Statement on Hormone Therapy.
Optimal management of menopause involves an individualized, holistic approach that includes lifestyle modifications, nutrition and exercise recommendations, disease prevention, and the use of hormone therapy based on a careful benefit/risk analysis specific to the individual.
BMS/RCOG and NAMS are aligned in abandoning specific age and duration limits for the use of HT. Rather, an individualized benefit/risk assessment at periodic intervals drives the decision for the duration of HT use.
BMS/RCOG and NAMS agree that HT should not be used without a clear indication and should not be prescribed for generalized, primary prevention of disease. However, when used for appropriate indications, HT is effective and may reduce all-cause mortality when used within the first 10 years of the onset of menopause in women < age 60.
Appropriate indications for HT based on the reviewed scientific evidence includes:
Vasomotor symptoms (hot flashes)
Prevention of osteoporosis
Genitourinary symptoms of menopause (vaginal dryness, painful intercourse, urinary symptoms)
Hypoactive Sexual Desire Disorder
HT is effective and FDA-approved for the prevention of osteoporosis.
BMS/RCOG promotes HT as an effective treatment for osteoporosis, however, in agreement with NAMS, recommends bisphosphonates as the first-line treatment of established osteoporosis.
Breast Cancer Risk
NAMS and BMS/RCOG do not recommend systemic HT in breast cancer survivors, however, there are possible exceptions in consultation with an oncologist, for debilitating menopausal symptoms when all non-hormonal treatments have failed.
For breast cancer survivors, NAMS states that low-dose vaginal estrogen therapy is likely a safe option, in consultation with the woman’s oncologist, for vaginal and urinary symptoms when non-hormonal measures have failed.
For women within the first 10 years of menopause and <age 60, breast cancer risk is extremely low and the benefits of HT for appropriate indications outweigh the risks.
Evidence suggests that breast cancer risk is linked to the type of progestogen (ie synthetic progestins) in combination HT products.
NAMS reports that although studies are limited, HT does not increase the risk of breast cancer in women with a family history or who possess BRCA gene mutations.
For more information on HT and breast cancer risk, check out last week’s Athletic Aging post: Breast Cancer Risk and Hormone Therapy - New Data Emerges
Thromboembolism (Blood clots in the deep veins)
For healthy women within 10 years of menopause and age <60, the risk of thromboembolism is small and the benefits of HT for appropriate indications outweigh the risks.
Several studies have suggested (but not definitively shown) that the transdermal route (skin patch, cream, spray) of HT administration may be less thrombogenic than the oral route. BMS/ROC supports the use of transdermal preparations as first-line for HT.
NAMS and BMS/RCOG are aligned in their recommendation that women who become menopausal before the age of 45 (due to either natural or iatrogenic (medical treatment) causes, be prescribed HT.
NAMS reports that HT reduces the risk for osteoporosis and related fractures, vaginal symptoms, and dyspareunia, with benefits seen in observational studies for atherosclerosis, cardiovascular disease, cognition, and dementia in women with premature menopause.
Estrogen/progesterone-containing oral contraceptive pills are commonly prescribed for prematurely menopausal women until the age of natural menopause at which time the decision is made to wean or transition to menopausal doses of HT.
Cardiovascular Disease Prevention
HT prescribed for appropriate indications in women <10 years since the onset of menopause and age <60 shows favorable effects on cardiovascular risk and all-cause mortality in many rigorous studies.
Data are mixed when considering HT for the sole indication of reducing cardiovascular risk. For this reason, NAMS and BMS/RCOG jointly recommend that HT should not be prescribed for the primary prevention of cardiovascular disease.
NAMS and BMS/RCOG are aligned in their recommendation that HT should not be used for the primary prevention of dementia or Alzheimer’s Disease.
Cognitive benefits are seen when HT is prescribed for women with premature menopause. However, the results of studies of women within 10 years of the normal onset of menopause and age <60 are neutral in relation to cognitive effects. In those > age 65, caution is advised given a small but notable increased risk of dementia in this older age group.
NAMS and BMS/RCOG report evidence that testosterone therapy is effective for the treatment of hypoactive sexual desire disorder in menopausal women.
BMS/RCOG reports a lack of evidence to support testosterone supplementation for the purpose of prevention or improving cognitive function, musculoskeletal health, improving bone density, or fracture prevention
NAMS and BMS/RCOG are aligned in the recommendation that compounded hormonal therapies should be avoided due to issues related to purity, potency, safety, lack of oversight, and rigorous study of specific custom formulations.
Both organizations recommend that FDA-regulated and conventionally licensed products be used as a first-line for any treatment.
For a review of this issue, check out my previous post in Athletic Aging: An Objective Look at Compounding Pharmacies and Their Role in Menopausal Medicine
In My Humble Opinion (IMHO)…..
Interpreting scientific literature is challenging - even for those of us in the field trained to do it. Compelling arguments can be made on both sides of many of these issues and are the subject of ongoing controversy. There is no clear “right” or “wrong”. Just data and a variety of interpretations.
So how do we as mid-life women make sense of it all?
Find reliable resources with reputable credentials and an evidence-based approach. The more you read, the more of a sense you will get for whether a piece is “opinion” or evidence-based.
Seek providers who will actively work with you to individualize your care.
Know that there is not always just one answer or option.
Find your tribe! You are not alone.
View yourself as the powerful, bad-ass woman that you are, ready to take on this next stage of life with a vengeance! .. not as a victim of a “disease” or a “deficiency.”
BMS / RCOG says it best….
“Menopause is a life stage and does not represent a deficiency state. Menopause should not be compared with conditions such as hypothyroidism or type 1 diabetes mellitus”
So, Game-On, my Friends! I hope you found this helpful.