Last month, the research round-up provided you with an overview of articles looking at prescribing in frailty. This month, we will look at a range of articles around management of the menopause. The first article examines the evolution of menopausal management in the UK and changes over the last decade. The second article explores the use of non-oestrogen therapies and complementary and alternative approaches in management of menopausal symptoms. Finally, in our third article we will review a study into the impact of hormone replacement therapy (HRT) and cancer outcomes.
The evolving perspective of menopause management in the UK
This article, published in the journal Women's Health, sought to evaluate the factors contributing to the apparent change in the perceptions of women and health professionals of the use of menopausal hormone therapy (MHT) in the UK. The aim was to review changes in the last decade that reversed the decline in the use of MHT after the publication of the Women's Health Initiative Study in 2002, which suggested an increase in breast cancer and heart disease associated with MHT (Rossouw et al, 2002).
‘New scientific data on the benefits and risks of menopausal hormone therapy (MHT), production of national guidance and an increased awareness on social media have all added to the rise in MHT prescribing’
The authors report that, since 2015, the UK has seen an increase in MHT prescribing compared to other European countries. They conducted an exploratory descriptive, qualitative study involving seven UK-based health professionals with a special interest in the menopause. The study took place as an interactive panel discussion guided by a moderator and carried out virtually over a 3-hour period. The panel was selected to be representative in gender (five female and two male health professionals), training and background (two gynaecologists, two GPs, two nurse prescribers and one pharmacist prescriber), clinical settings (private and NHS clinics) and geographic location (affluent and deprived areas).
The panel was tasked with three objectives: evaluating factors contributing to the shift in perception of MHT use in the UK; understanding how changes to women's perceptions of MHT influences consultations with health professionals; and to engage in robust and informative conversation about the evolution of menopause care and management in the UK. The goal was to elucidate key points of learning that could be applied to other countries.
The article makes clear that in the last 8 years, there has been an increase in MHT prescriptions in the UK. The reasons and drivers for this include increased menopausal awareness, better access to information, publication of new scientific evidence and updated national guidelines from institutes such as NICE (2019) and information from the British Menopause Society.
The panel looked at current provision of MHT care and highlighted some key areas, including provision of care and settings, rationale and safe prescribing of MHT, patient information and training of health professionals. They suggest that there are differences in menopause care across the UK, which may be attributed to factors such as a lack of health professionals with a special interest, little consensus in terms of local guidelines, and low availability of some MHT preparations. They acknowledge that differences in health literacy of the population have led to a shift in the demographic of women coming forward to seek alleviation of symptoms, and the significant influence of the media.
The authors conclude that new scientific data on the benefits and risks of MHT, production of national guidance and an increased awareness on social media have added to the rise in MHT prescribing and improvement of menopause care in the UK. They suggest lessons learned may benefit other European countries.
Non-oestrogen-based and complementary therapies for menopause
This article, published online in the journal Best Practice & Research Clinical Endocrinology & Metabolism is a good overview of non-hormonal (non-oestrogen based) and complementary therapies for the management of symptoms in the menopause.
The article starts by defining menopause and acknowledging that HRT is the mainstay of treatment for menopausal symptoms with the use of oestrogen, progestogen and sometimes testosterone to replace the reduced sex hormones characteristic of menopause. The symptoms that these are typically aimed at relieving are hot flushes, night sweats, mood swings, heightened anxiety, brain fog, reduced libido, vaginal dryness and sleep disturbances.
They acknowledge that each woman has a unique experience of menopausal transition and, therefore, a person-centred, holistic approach is needed. This may consist of HRT, non-hormonal medications, lifestyle changes and complementary and alternative therapies, or a combined approach. It is worth noting that some women may have contraindications to HRT or suffer significant side effects, and other management approaches need to be considered.
The article provides an overview of non-hormonal approaches to management of menopausal symptoms. This includes medications such as clonidine, SSRIs, gabapentinoids, isoflavones and soya products, and neurokinin 3 receptor antagonists. The article summarises their use and evidence, such that some studies show that SSRIs, SSRI/SNRIs, gabapentin and pregabalin are effective for managing vasomotor symptoms as well as other menopausal symptoms, but they are not without side effects.
They note that clonidine is the only non-hormonal drug licensed for vasomotor symptoms in the UK, but it can have side effects including dizziness and sleep disturbance.
Non-pharmacological approaches reviewed are lubricants for vaginal dryness, and complementary and alternative treatments for vasomotor symptoms. The latter includes herbal treatments, behavioural therapies, acupuncture, hypnosis, mindfulness, yoga, meditation and ganglion block.
The authors present information that CBT is recommended as a treatment for anxiety, sleep problems and vasomotor symptoms related to menopausal transition. They are inclined to agree that evidence for clinical efficacy and safety of herbal remedies and alternative therapies remains weak.
It is concluded that an individualised treatment of menopausal symptoms based on nature of symptoms, past medical history, family history and personal choice is currently recommended and that a ‘one size fits all’ approach should not be used. They also recommend that as good-quality research in some areas is lacking, robust studies with large participant numbers are needed to inform care.
HRT and cancer mortality in women with 17 site-specific cancers: a cohort study using linked medical records
This article, published in the British Journal of Cancer, sought to examine HRT use and cancer mortality in women with 17 site-specific cancers. The researchers used data from three national databases in England, Scotland and Wales to group participants into population-based cohorts. They included women aged 40–79 who had been newly diagnosed with 17 site-specific cancers.
The records between 1998 and 2019 excluded patients with breast cancer due to HRT being contraindicated in this diagnosis group. The researchers then obtained HRT use from electronic prescribing and dispensing records. The outcome of interest was cancer-specific mortality and the time to this after diagnosis. This was because the primary interest was to determine if there was an aetiological effect of HRT on cancer specific mortality.
The data included 182 589 women across the 17 cancers included and the time period sampled, who survived more than 6 months after diagnosis. In that sample, 7% of participants were on systemic HRT after being diagnosed with cancer. There was no evidence that HRT users compared with non-users had higher cancer-specific mortality at any cancer site. Use of HRT was associated with reductions in cancer-specific mortality in women with colorectal, ovarian, uterus, kidney, oral and non-Hodgkin lymphoma, but these associations were based on relatively small numbers or were generally not consistent across sensitivity analyses.
The researchers suggest that their study may provide some reassurance to clinicians and patients of the safety of systemic HRT in women with one of the 17 cancers studied, but this should be interpreted cautiously in women with oestrogen-sensitive cancers.
Conclusion
HRT is commonly used as a therapeutic method of reducing the troublesome and problematic symptoms of the menopause for many women. It is, however, important to consider other pharmacological and non-pharmacological approaches to symptom management, and to adopt a patient specific and holistic approach to interventions, as each woman's experience is unique.
Research findings and guidelines can be useful in considering the range of treatment options, but patient information and education allowing for shared decision making should be the standard approach for all clinicians involved in menopausal care.