Concern over unproven menopause treatments

Menopause is a natural part of life.
 
But genitourinary symptoms – which are estimated to affect more than 50% of post-menopausal women – can significantly impact a woman’s quality of life.
 
In the search for some relief, however, there are concerns women are being targeted with unproven, and often expensive, treatments, such as fractional carbon dioxide vaginal laser.
 
Tasmania-based GP and Australasian Menopause Society (AMS) President Dr Karen Magraith is among those trying to raise awareness.
 
‘My main concern is that women may be spending a lot of money on treatments when there is currently insufficient evidence of lasting benefit,’ Dr Magraith told newsGP.
 
‘Some women may experience a short-term improvement, but we can’t rule out a significant placebo effect.
 
‘It’s also possible that the treatment could cause harmful effects, such as pain or scarring. This wasn’t seen in the Australian study, but it could occur with less skilled practitioners.’
 
In addition to the risks – both physical and financial – Dr Magraith says if women are being offered laser as a first-line treatment they could be missing out on a suitable assessment and discussion about other options that may help them.
 
A common concern for menopausal women is vaginal dryness, which can cause sex to be painful.
 
But Dr Magraith says the taboo that lingers around the topic means women are sometimes nervous to raise it with their GP, which can make women vulnerable to expensive or unproven treatments.
 
‘Many women at mid-life have multiple responsibilities in their lives; they may be dealing with adolescent children or ageing parents, a challenging job or changes in relationships – a lot of them are fatigued,’ she said.
 
‘They may face symptoms of perimenopause or menopause and they have a dilemma – on the one hand the symptoms are normal or natural, and shouldn’t be medicalised, but at the same time women can find them very difficult, and in many cases, can benefit from medical treatments.
 
‘[So they] are looking for effective treatments, and laser or radiofrequency treatments seem to offer a solution that works quickly, [and] the fact that it is “high tech” can make it more attractive.’
 
Beyond laser treatments, women are also buying expensive custom-compounded bio-identical hormone products, when they could be getting TGA-registered body identical products that are regulated and have available safety data, at a lower cost.
 
For women who are experiencing concerns with sexual function, whether it be vaginal dryness, low libido or other concerns, Dr Magraith says they would benefit from an assessment that considers all the factors that may be contributing.
 
‘This can include fatigue, mood issues, sleep and relationship issues, as well as considering whether there may be other vaginal or vulval conditions contributing,’ she said.
 
‘It’s important that the assessment be patient-centred.
 
‘Some women may feel under pressure to continue having sexual activity when they really don’t want to. It’s about what is important to the woman herself, not her partner or society in general.’
 
Eligible women who have menopausal symptoms, such as vasomotor symptoms, may choose to have systemic menopausal hormone therapy, which often helps vaginal dryness, but vaginal moisturisers and lubricants can also be helpful.
 
Meanwhile, vaginal estrogen, Dr Magraith says, is a safe and effective alternative for the treatment of vaginal dryness and the urinary symptoms associated with menopause.
 
‘Patients do need to use the treatment for a number of weeks or months before they see a benefit, and it needs to be continued for the benefit to continue,’ she said.
 
‘Vaginal estrogen has minimal systemic absorption and because it is available on the PBS it’s much cheaper than vaginal laser.
 
‘I don’t know why six-months’ worth of repeats are not available on the PBS – it would be great if this changed.’
 
However, if a GP is considering vaginal estrogen treatment for women with a history of breast cancer, Dr Magraith recommends they contact the patient’s breast cancer specialist to discuss the proposed treatment as it may not be suitable for some.
 
Ultimately, Dr Magraith believes society should not impose expectations about how women deal with menopause, and says shared decision-making with a trusted GP ‘can be very helpful’.
 
‘It helps if GPs routinely ask about genitourinary symptoms when discussing other aspects of menopause,’ she said.
 
‘And, ultimately, it is for the woman herself to decide what her approach to menopause will be and whether she will use medical therapies.’
 
With patients becoming increasingly aware of perimenopause, and often presenting to GPs earlier in the menopause transition, Dr Magraith says GPs would benefit from more education to be better equipped for these consultations.
 
‘Management of menopause should be part of mainstream general practice,’ she said.
 
‘But it can be challenging because of the need for a comprehensive assessment, and because of the complexity of the information about hormone therapy.
 
‘Consults need to be individualised because every patient’s experience and needs are different.’
 
Dr Magraith, however, believes that the current Medicare system acts as a ‘significant disincentive’ for women seeking longer or more complex consultations, and for the doctors who provide them.
 
‘This needs to change for women to be able to access the care they need,’ she said.
 
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