Menopause: Time for change
Women need clear, evidence-based information to break through the conflict and confusion about menopause treatments
Often referred to as “the change”, the menopause refers to the biological stage in every woman’s life when their periods stop and the ovaries lose their reproductive function. Usually, this occurs between the ages of 45 and 55, but in some cases, women may become menopausal in their 30s, or even younger.
The recent launch of the NICE guideline on the diagnosis and management of the menopause was a monumental menopausal moment! For the first time, leading experts in the field have examined all of the existing evidence and we have been presented with information and advice which will not only enable women to better understand the consequences of the menopause and make informed choices about their treatment, but also ensure that healthcare professionals can provide women with evidence-based information about the benefits and risks of different treatment options in order to come to decisions on an individual basis.
Every woman experiences the menopause differently. Symptoms can last from a few months to several years and up to 80% of women experience physical and/or emotional symptoms during this time. These can include; hot flushes and night sweats, tiredness and sleep disturbance, joint and muscle ache, mood swings and depression, forgetfulness or lack of concentration, vaginal dryness and loss of interest in having sex.
With life expectancy at 83.2 years, many women are living in this post-menopausal phase for half to one third or their life, and these symptoms can have a significant impact on their health and wellbeing as well as their work and relationships. The menopause is not something that just affects ‘older women’ but those in ‘mid-life’ - often when they are juggling demanding jobs, school-age children and elderly parents. Despite this, many women are unaware of the impact of symptoms and later health problems and that diet and lifestyle changes can help improve their symptoms. Sadly, many are also often confused about the benefits and risks of treatment options.
We know that many women choose to go through the menopause without seeking treatment. Others prefer to help to manage their symptoms either by using hormone replacement therapy (HRT) or an alternative treatment option such as cognitive behavioural therapy, relaxation techniques or herbal medicines such as black cohosh, isoflavones (plant estrogens) or St John’s wort.
HRT has been controversial for many years and has frequently divided opinion. The evidence underpinning the benefits and risks has been accumulating for many years and this guideline has focused specifically on the risks of breast cancer, heart disease, stroke and bone health in women aged between 50 and 59.
This guidance is unequivocal in recognising that HRT is an effective treatment for menopausal symptoms, particularly with the management of hot flushes. However, the benefits and risks will stack up differently for each woman, and whether or not to take HRT is an individual choice.
Let’s start with the good news. The evidence tells us that HRT not only reduces symptoms but can also improve bone health and reduce the risk of osteoporosis and fractures in later life.
The slight increased risk of breast cancer associated with HRT has been widely documented and is not disputed in this guidance. To put this into perspective, breast cancer is the most common cancer in women and approximately 23 in every 1,000 women in the general population will suffer from breast cancer over a period of 7.5 years. For women taking estrogen and progesterone HRT, we will see around five extra cases of breast cancer over the same timeframe. Estrogen only treatment, which is given to women who’ve had a hysterectomy, shows four fewer cancers in same time frame. It’s the progesterone which appears to have effect of increasing disease. This risk is related to the treatment duration and reduces after stopping HRT, suggesting that HRT may, in a small number of women, promote the growth of breast cancer cells which are already present rather than cause the cancer .
Heart health and stroke risk are other areas that are widely debated. Looking at the most recent evidence from the Cochrane collaboration, we can conclude that if 1,000 women under 60 years old started HRT, we would expect six fewer deaths, eight fewer cases of heart disease and five extra blood clots over about seven years, compared to 1,000 similar women who did not start HRT.
We must remember that HRT is just a small component of post-reproductive health and the treatment of menopause depends on a clear and complete understanding of an individual woman’s circumstances as well as the health of women in their later years. Our focus as healthcare professionals is to ensure that women receive clear, evidence-based information to help them make decisions about their health.
It’s also important to remember that lifestyle factors such as obesity and smoking play a huge role in a woman’s short and long-term health and we encourage all women, no matter what their age is, to maintain a balanced diet, engage in regular physical activity and refrain from smoking. This advice is particularly relevant for menopausal women, as lifestyle factors – particularly being overweight - impacts on the severity and length of menopausal symptoms and on later health.
Women deserve high-quality information on their choices. Although we appreciate that too much information may be confusing for women, who may want their health professional to tell them ‘what’s best’, managing the menopause is an area of medicine that is truly individual and we hope this guidance will empower both health professionals and women to work together on deciding the best treatment options for them.---