Almost three-quarters of perimenopausal women report symptoms such as hot flushes or night sweats, and women with moderate to severe symptoms often experience them for a decade or longer. These symptoms may cause debilitating mood changes, difficulty concentrating and impairment of short-term memory. Untreated menopausal symptoms are also associated with higher healthcare costs and loss of work productivity.

The use of systemic hormone therapy has decreased by as much as 80% among women in the US since 2002 when the initial findings of the Women’s Health Initiative (WHI) were published.¹ The WHI trial was designed to address the risks versus benefits of long-term use of hormone therapy for the prevention of chronic disease in postmenopausal women who were on average 63 years of age at the initiation of therapy. 

Concerns were raised about small but significant increased risks of coronary heart disease, stroke, deep vein thrombosis (DVT) and breast cancer in postmenopausal women treated with oestrogen/progesterone combinations. However, for oestrogen-only preparations there is only a slight increase in the risk of DVT, with significant reductions in the risk of diabetes mellitus and bone fractures.¹

Concerns about side-effects of hormone therapy have resulted in a substantial decrease in its use and newly graduated doctors and primary care providers often lack training and core competencies in the management of menopausal symptoms and prescribing of hormonal (or non-hormonal) treatments. Approved hormonal treatments for menopausal symptoms are now used infrequently even though the understanding of their benefits and risks has never been clearer. As has been pointed out by Manson et al in a comprehensive overview of the findings from the two WHI hormone therapy trials, the absolute risk of adverse outcomes is much lower in younger women than in older women; the net effect on all-cause mortality in younger women is neutral or even favourable.¹

In addition, new hormone formulations, including those with lower doses and transdermal routes of delivery, are now available for treatment of menopausal symptoms, as are non-hormonal options including selective serotonin-reuptake inhibitors, norepinephrine-reuptake inhibitors and gabapentinoids. However, non-hormonal options tend to be less effective than hormone therapy.

A reluctance to treat menopausal symptoms has derailed and fragmented the clinical care of midlife women, creating a large and unnecessary burden of suffering, according to Manson. Clinicians who keep up to date on hormonal and non-hormonal treatments can put menopause management back on course by equipping women to make informed treatment choices. In addition, it is vital to train the next generation of healthcare providers and equip them with the skills to address the current and future needs of this patient population.

References

1. Manson JE, Chlebowski RT, Stefanick ML et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA 2013; 310: 1353-1368 doi: 10.1001/jama.2013.278040