Consider MHT for bones: New menopause guideline

Hormone therapy is under-prescribed for targeting bone health, according to experts who recently published the 2023 Practitioner’s Toolkit for Menopause Management.
 
The first update since 2014, the toolkit is the first of its kind to provide guidance for using such treatment to maintain bone health and prevent fractures. It aims to provide GPs with the most up-to-date clinical guidance around prescribing menopausal hormone therapy (MHT) and optimising mid-life care for women.

GP and Immediate Past President of the Australasian Menopause Society, Dr Karen Magraith, is one of the authors of the 2023 toolkit.
 
She told newsGP a large reason for the update is that MHT is under-prescribed specifically for bone health.
 
‘There’s been a lack of clarity with guidelines on when we can consider prescribing hormone therapy for bone health,’ Dr Magraith said.
 
‘This guideline tries to bring some more practical assistance for practitioners.’
 
The revised toolkit recommends GPs consider prescribing MHT solely for bone health for women aged under 65 with a T-score of -1.8 or less, saying it will likely reduce the risk of fractures in this cohort who are asymptomatic and postmenopausal, with benefits outweighing any potential risk.
 
According to the resource, this provides a ‘pragmatic, conservative, cut-off point’ after which fracture risk increases in postmenopausal women aged over 65.
 
‘When applying this cut-off, both the individual’s BMI and time since menopause need to be taken into consideration,’ the guideline states.
 
‘MHT has been shown to prevent bone loss and fragility fractures in all postmenopausal women irrespective of BMD and other risk factors.’
 
Lead author of the toolkit Monash University Professor Susan Davis recently told the ABC with MHT being under-prescribed for maintaining bone health, the new guidelines provide targeted guidance for GPs on when to prescribe.
 
‘We know from research that GPs don’t feel confidence in prescribing it, so this aims to clear up a lot of the confusion out there,’ she said.
 
‘A lot of GPs go straight for the bone drugs and we are basically saying, “Do you really need to go to the big guns or can you take a step back and consider hormone therapy for a few years?”
 
‘You want to stop someone who has low bone density from progressing to osteoporosis, and you will do that with hormone therapy, in most cases.’
 
Dr Magraith notes that while for many, the benefit of taking MHT to prevent fractures will outweigh any potential risks, each woman needs to have an individual assessment of her own risks in relation to prescribing hormone therapy.
 
‘It’s not a blanket statement that anybody should be put on it, but we should be considering it, along with all the other things we usually consider regarding bone health, such as calcium and vitamin D intake and physical activity,’ she said.
 
‘And we should be considering hormone therapy even if the patient does not have symptoms of menopause – and that’s a little bit different to some of the previous advice.’
 
While RACGP and Healthy Bones Australia (formerly Osteoporosis Australia) guidelines discusses hormone therapy, the new toolkit provides further clarity and guidance about when to consider prescribing MHT for asymptomatic women with low bone density, not just those with osteoporosis or calculated to be at high risk of fracture, according to Dr Magraith.
 
‘To my knowledge, [the toolkit] is the one that is most specific about this sort of prescribing,’ she said.
 
Endorsed by the International Menopause Society, Australasian Menopause Society, British Menopause Society, Endocrine Society of Australia and Jean Hailes for Women’s Health, the toolkit provides the full range of available options for managing menopause.
 
Dr Magraith said while many GPs may be familiar with the toolkit and have been using it since 2014, the refresh is designed to assist with shared decision-making during consults.
 
‘It’s practical, with an algorithm that GPs can refer to which talks about options for treatment, including hormone therapies, and other non-hormonal options,’ she said.
 
‘It gives information about what sort of things to include in a mid-life women’s health assessment. It is recommended that all women have an assessment of their health around the time of menopause even if they don’t have symptoms.
 
‘That assessment should include things like cardiovascular disease risk, bone health and where they’re up to with breast screening, cervical screening, etcetera, and a discussion of lifestyle management.’
 
The toolkit also recommends more widespread bone mineral density (BMD) testing than what is currently practised – a key point Dr Magraith said was raised when developing the update.
 
It suggests the need to consider doing a BMD test, especially for women with risk factors for poor bone health. For example, BMD testing ‘when possible’ for women with normal or low body weight, along with a range of clinical indicators for testing.
 
Acknowledging the wide-ranging lifestyle impacts of menopause, Dr Magraith says the toolkit aims to cover all bases.
 
‘We also talk about the health consequences of menopause,’ she said.
 
‘Including the importance of managing metabolic health, which is an important thing to consider because it’s not just about treating the symptoms.’
 
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bone health fracture risk hormone therapy HRT menopause management MHT women’s health