I love the fact that when I opened this week’s issue of “The New England Journal of Medicine” I found that the second article was titled, “Menopause Management – Getting Clinical Care Back on Track”. I hope I don’t sound like a broken record, but I’ve been talking about “menopause neglect” for years and want to reiterate the topic (with the help of this article) once more…
Let’s start with the fact that 50 million women will be older than 51 by 2020. Three quarters of women report menopausal symptoms of hot flashes and/or night sweats which can last for a decade or longer. And just to point out the obvious, hot flashes can disrupt sleep and hence cause mood changes, difficulty concentrating and impairment of short-term memory. Despite the very significant health consequences of these symptoms in a huge portion of the population, the authors state that the new generation of medical graduates in both primary care and obstetrics and gynecology lack the training for their management.
In general, the use of hormone therapy has decreased by as much is 80% among US women since the initial findings of the Women’s Health Initiative (WHI) which were published in 2002. The original study comparing women who took Premarin and Provera to control women who had no hormone therapy was conducted in participants over the age of 63. It was abruptly stopped (with much publicity and too early) because there appeared to be a higher risk of adverse medical events in the women who took the two medications. The problem with the study was that it was conducted in older women who had few or no hot flashes and often had underline coronary vascular disease and other medical issues. Subsequent ongoing studies have shown that in the right patients, lower doses given in different formulations not only stop the hot flashes, but in younger women the hormone therapy protects them from heart disease and bone loss.
Currently, professional societies including the North American Menopause Society, the American College of Obstetricians and Gynecologists, and the Endocrine Society support the use of systemic hormone therapy in symptomatic, recently menopausal women who don’t have contraindications such as, an excessive risk of breast cancer or cardiovascular disease. They feel that the benefits of hormone therapy likely outweigh the risks. The authors add that vulvar vaginal atrophy i.e. vaginal dryness occurs in up to 45% of women in midlife or later and can adversely affect their physical and sexual health and quality-of-life. Low dose vaginal estrogen has been found to be effective and is considered safe. (It is not systemically absorbed, and is even prescribed in patients who have had breast cancer.)
I have often written about the concerns regarding non-FDA approved medications. The authors state that “the gap in appropriate treatment has left an opening for a huge market of untested and unregulated, alternative treatments including compounded hormone products that are not regulated by the FDA”. There are concerns about their consistency, contamination and unsubstantiated safety and efficacy claims. A recent survey of 3725 postmenopausal women conducted by the North American Menopause Society estimated that 35% of current hormone therapy users are taking a compounded hormone product.
Paradoxically, although FDA approved hormone treatments have been extremely well studied, with regard to their balance of benefits and risks, they are often considered too controversial to prescribe or take, even for women in their 50s. I guess both future physicians as well as their female patients need to receive appropriate hormonal education. There will be more and more of us who want our symptoms controlled!