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Outdated information still guides menopause management: Expert


Evelyn Lewin


26/03/2021 1:53:35 PM

Understanding the risks and benefits of various menopausal therapies leads to better outcomes.

Female GP talking to middle-aged female patient
Menopause treatment should be tailored to the individual.

‘Fall out’ from a nearly 20-year-old study is still impacting the clinical management of menopause in Australia, a women’s health specialist has told newsGP.
 
The Women’s Health Initiative (WHI) Hormone Therapy Trials, published in 2002, examined primary efficacy and safety outcomes for coronary heart disease, osteoporosis and invasive breast cancer in midlife and older postmenopausal women starting menopause hormone therapy (MHT).
 
It concluded that while hormone therapy is appropriate for symptom management in some women, its use for chronic disease prevention was not supported.
 
But, Dr Fiona Jane, a GP at Jean Hailes and a Research Fellow at the Women’s Health Research Program at Monash University, says recent research now indicates the results from this study on harm were ‘exaggerated’ and varied with age.
 
Yet according to Dr Jane, these newer pieces of information have not filtered down to clinicians and patients.
 
‘In parts of general practice there’s still a reluctance to prescribe some therapies, particularly menopause hormone therapy, and in the community amongst women there’s still a perception that these therapies may not be safe,’ she said.
 
‘Even though there’s been re-analysis of the data and new studies have changed our understanding of the risks and the benefits of menopause treatment [since the WHI study], that updated information may not be out there as much as we would like it to be.’
 
Dr Jane says the research shows adverse effects of MHT in women who were within 10 years of menopause ‘were very uncommon’, and that the WHI results were also based on findings using predominantly older hormonal formulations.
 
‘Now we’ve got body-identical hormones,’ she said.
 
‘Not compounded bio-identical – therapies which are not approved by the Therapeutics Goods Administration [TGA] or any menopause society or groups in the world – but body identical.
 
‘These are hormones chemically similar to the oestrogen and progesterone hormones that are naturally produced from our ovaries.’
 
And, there are important reasons for clinicians to remain abreast of these updates.
 
‘I had a colleague say to me a number of years ago, “Oh, I believe the old preparations are the best preparations; they’re tried and true”,’ Dr Jane said.
 
‘[But] he was referring to oral oestrogens, which we now know have a higher risk of venous thromboembolism than transdermal oestrogen and older progestins.’
 
In the past five or six year there have been significant changes in the management of menopause she says, including the release of the Revised global consensus statement on menopausal hormone therapy in 2016.
 
Some of the points covered in that statement include:

  • MHT, including tibolone and the combination of conjugated equine oestrogens (CE) and bazedoxifene (BZA), is the most effective treatment for vasomotor symptoms (VMS) associated with menopause at any age, but benefits are more likely to outweigh risks if initiated in symptomatic women before age 60, or within 10 years after menopause
  • if MHT is contraindicated or not desired for treatment of VMS, selective serotonin re-uptake inhibitors and serotoninnorepinephrine re-uptake inhibitors such as paroxetine, escitalopram, venlafaxine and desvenlafaxine, which have been shown to be effective in randomised controlled trials, may be considered. Gabapentin may also be considered
  • MHT, including tibolone and CE/BZA, is effective in the prevention of bone loss in postmenopausal women.
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Dr Fiona Jane says GPs need the confidence to both diagnose and manage menopause.
 
However, while managing menopause appropriately is fundamental, clinicians also need to feel comfortable identifying and diagnosing it in the first place.
 
‘GPs need the confidence to recognise the symptoms and signs [of menopause], including when it occurs in young women under 40, such as in primary ovarian insufficiency,’ Dr Jane said.
 
‘They need to know what tests, if any, need to be done because menopause is generally a clinical diagnosis.’
 
Once diagnosed, she says doctors should be aware of the risks and benefits of hormone therapy, as well as other non-hormonal treatments and complementary medicines that can be used to treat menopause.
 
‘They need to know the key principles in managing and treating, because women need really clear information so they can make decisions about their individual circumstances,’ Dr Jane said.
 
‘It is important GPs keep up-to-date with the newer preparations, understand the differences in the risk/benefit scenarios, and are able to tailor management to the individual woman.’
 
When a patient presents with menopausal symptoms, clinicians should also be prepared to use that consultation as a ‘springboard’ for discussions about preventive health and ‘general wellness’ in midlife.
 
‘If [menopausal patients are] otherwise well, they may not have had general checkups and screening tests, and this is a great time for GPs to jump in [and do them],’ Dr Jane said.
 
‘It is the ideal time to check a woman’s cervical screening tests and mammograms are up-to-date, to review blood pressure and bloods as appropriate, and discuss general issues such as her diet, medications and physical activity.’
 
Dr Jane says managing menopause remains challenging due to the changing landscape, the variety of treatments available, and the need to know their risk and benefit profile and then tailor this information to each individual who is experiencing troublesome symptoms.
 
That is why she is passionate about a new e-course by Jean Hailes on managing menopause.
 
She says the course provides the latest information on treating menopause, along with videos of experts discussing treatment, access to relevant papers, resources and international consensus statements, links to management algorithms, and equivalent dosing of MHT.
 
‘There’s a lot of really good evidence-based data there,’ she said.
 
Managing menopause is an RACGP CPD-accredited activity with 40 allocated points.
 
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