Menopause Management

New data emerging from the Women’s Health Initiative study into the use of hormone therapy (HT) for menopausal women has prompted guidelines for medical practitioners and women wanting to make informed health choices.

In the five years since the American study ended, new information has emerged around the use of HT in relation to cardio-vascular disease, cancer and osteoporosis. When one of the trails in the study was suspended in 2002 because the health risks appeared to outweigh the benefits, it triggered a panicky rejection of HT by many women and their healthcare providers. However the last scientific response to the data reflects a shift back to a middle ground of HT use for younger menopausal women. An important factor in understanding this shift in attitude is to realize that the original WHI study was a study on women whose average age was 64years. In the study women were being started on hormone therapy in their mid 60’s and in their 70’s. This is completely unlike the real-life situation where HT is started in the early 50’s when symptoms are most severe. The new guidelines follow reanalysis of the results of those studies looking at the effects on different age groups particularly those patients between 50 and 59 years who are the most likely group who will need HT.

When the estrogen only (ET) and estrogen plus progestin (EPT) arms of the WHI study were analyzed together, researchers found a 30% lower mortality rate in the women using hormones compared with non-users -provided that the HT was initiated less than ten years after the onset of menopause. (The average age of menopause is 51.) In this group the overall incidence of heart disease events was significantly decreased in users of HT.

One of the main elements in the latest guidelines has to do with the use of ET compared with EPT.

In the estrogen only arm of WHI, no increase in breast cancer was seen over the seven-plus years of the study. In addition, the younger patients (between 50 and 59) who took part in this trail showed a decrease in overall cardiac events. This has lead to a “window of opportunity theory” which suggests that early use of estrogen is beneficial to blood vessels. However, if ET is delayed and used in older women in whom vascular damage has already occurred, the effect could be detrimental.

HT in relation to osteoporosis also gets a nod of approval. The new SAMS position is that hormone use should be considered a first line of treatment for younger menopausal women with osteoporosis.

The main indication for the use of HT is for the treatment of those symptoms that are distressing for menopausal women:

• Hot flushes, night sweat and sleep disorders because HT remains the only treatment that consistently has a greater effect than placebo in published controlled trails.
• Preventing and treating urinary problems and vaginal conditions such as dryness, atrophy and painful intercourse. For less severe symptoms, local ET is favoured (usually in the form of a vaginal cream or tablet). It was previously held that a four to five year safety period was necessary for the use of HT. The new thinking does not stipulate the timelines for stopping hormone use. The duration should be assessed according to the individual needs for every woman and be reviewed annually—but, in general, HT should not be started after a woman has turned 60. The principle of the lowest effective dose remains as this has been effective for controlling symptoms and preventing bone loss.

The new guidelines do not give a green light to the use of HT for every woman going through her menopausal years. Concerns remain around the following:

• Breast cancer. The use of estrogen combined with progestin for more than five years may be associated with a small increase in the risk of invasive breast cancer. It’s possible that the hormone therapy does not cause the cancer but stimulates pre-existing malignancy that would have occurred at a later stage without the use of HT.
• It is recommended that women undergo breast screening as well as a pelvic examination before starting HT. All menopausal women should have regular mammography.
• Thrombosis. There is a small increased risk of blood clot formation but this possibility decreases after the first year of treatment.. The risk for thrombosis maybe less if transdermal (through the skin) estrogens are used instead of the oral variety.
• Stroke. While the WHI study revealed an increased risk for thrombotic stroke, it is now felt that there is not enough evidence about the effect of HT on stroke. Some data suggest that HT may only increase the risk of stroke when other factors such as hypertension are present.

Research into the use of plant estrogens and herbal formulations has not produced results from which SAMS can make confident recommendations about treating menopausal symptoms. No published data is available on the use of traditional African medicine.

Decision-making around menopause management not only involves the decision of whether or not to use HT but also the beneficial effect on quality of life which can only be judged by each individual woman.

The menopausal years should be used as an opportunity to look at all the health matters concerning the second half of a woman’s life. Lifestyle modifications that can be addressed include stress reduction, weight management, exercise, smoking cessation as well as monitoring for diabetes, hypertension (high blood pressure), bone density, breast and arterial health.

Undertaking HT must be a joint decision between healthcare provider and an informed woman, based on relevant clinical factors and ongoing scientific evidence.

Read more about the SAMS guidelines on the website: www.menopause.co.za