Delayed recognition and management of the menopause: at what cost?

Abstract

Having had the privilege to provide care for menopausal women for more than 20 years and having seen the beneficial effects on women, their families, friends and work colleagues on appropriate management of menopausal symptoms, we were saddened to read the article in news and views on money saved from reduced use of hormone replacement therapy (HRT). As explained in the text, the alleged savings from reduced cases of breast cancer and cardiovascular disease are questionable, since the research from which these figures were taken (Women’s Health Initiative (WHI) trial) has been reanalysed many times and it has been concluded that HRT with estrogen plus progestogen may or may not increase the risk of breast cancer, but the WHI did not establish that it does. Regarding estrogen-only HRT, reanalysis concluded that unopposed estrogen does not increase the risk of breast cancer, and may even reduce it. It has become clear that cardiovascular risk was only increased in women many years postmenopause. Indeed, the women who took HRT under the age of 60 showed a reduced risk, as has been confirmed by more recent randomised controlled trials, confirming potential benefits from the ‘Window of Opportunity’ theory. Furthermore, increased numbers of cases of osteoporotic fracture are now being reported since HRT use has declined, and even more concerning was the study which reported increased mortality rate in women having hysterectomy with less use of HRT thereafter. The arguments about this could go on and on – days could be spent calculating bed days, hospital visits, GP visits, charges for other medications, the list goes on. Whether HRT use costs the healthcare system more or less money, the greater cost is undoubtedly to women as a result of the highly publicised risks and ongoing lack of interest and support to these women. How can we measure the effect on relationships, work output and overall quality of life of low mood, anxiety, irritability, disturbed sleep, tiredness, joint aches and difficulty coping with life in general? (The well-known symptoms of hot flushes have been purposely left out of this list, not because they are not important but to emphasise the fact that treating menopausal symptoms is not just about hot flushes!) As editors, we have previously suggested that not to address these issues when there are acceptable means of treatment could be negligent. As the evidence base grows, we are becoming more convinced of that opinion. Will we ever know how many relationships have ended with considerable distress on the whole family, simply due to untreated genitourinary syndrome of the menopause causing discomfort during sex, reduced libido and relationship stresses? Whatever the cost of either using or not using hormone replacement or alternative therapies, women need to come first and for many, managing their menopause either by themselves or with support from each other or from healthcare professionals, can have benefits which can never be measured. While managing menopause is not just about treating hot flushes, it is also not just about use of HRT. While it is now clear that the appropriate use of HRT provides more benefits than risks for most women, the most important aspect is that women feel listened to and not ignored. They should feel that their management plan is individualised to best suit their personal and medical needs, not given a blanket, one-size-fits-all approach, and that they receive accurate advice to include diet and lifestyle advice that will improve later health as well as helping early symptoms, not just advised for the short term. To return to the question, ‘At what cost?’ we suggest a way forward. Firstly, visit the BMS website or come to one of our meetings and refresh your knowledge using the evidence and statements from organisations that exist to give you the confidence to manage the menopause in the way that you feel is best. Then try to give yourself the time to look after the women you see who are menopausal, to help them become fully informed, with minimal or no symptoms, taking control of their lives, being active, successful at work, and enjoying life. Isn’t that what it’s all about?!