Millions of women in Ireland and the UK are perimenopausal and menopausal.
It is a health concern that as a society we can ill-afford to ignore any longer; not only in how we help women relieve symptoms but in how we can safeguard their health.
In recent years more attention has been given to the fact that the perimenopause (the time directly before the menopause) can trigger numerous health issues. The list of potential issues is a long one: cardiovascular disease, osteoporosis, type 2 diabetes, neurological symptoms such as hot flushes, disturbed sleep, mood changes and forgetfulness, Alzheimer’s disease, low self-esteem, clinical depression, breathing difficulties, anxiety, tiredness, irregular and/or heavy periods, joint pains, vaginal dryness and decreased sex drive.
Any one of these issues can have a significant impact on quality of life.
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Hormone Replacement Therapy (HRT) — which replaces hormones that decline during perimenopause and menopause — can ameliorate such symptoms and reduce risk of disease. But crucially, the research is also suggesting that many of these problems can be prevented or reduced by taking HRT in the “critical window” of the early stages of menopause and also in the perimenopause.
This could, and should, revolutionise our attitudes to HRT, which have been overshadowed by incorrect interpretation of data and alarmist headlines that led to ill-informed decisions and plummeting numbers of women taking HRT in the 2000s.
Put simply, HRT is more than a mere “fix” for menopause symptoms and many more women should consider taking it.
The Lancet, one of the world’s oldest and most respected medical journals, recently published two articles and an editorial about menopause. One of these articles argued that HRT should be seen as an important preventative therapy that can enhance quality and length of life. We believe that this, along with an increasingly strong body of research to back up such a claim, should be a game changer for menopause care and, more to the point, women’s lives.
Why? Because women are needlessly succumbing to diseases, dying earlier and have an overall lower quality of life. Of course, some women do not experience many or any of the symptoms listed above, so don’t see the need to take HRT.
However, research suggests that these women are mistaken; and that these women will be risking their cardiovascular health, their bone health and, possibly, their neurological health by avoiding HRT. They too, on this account, should think seriously about the preventative benefits of HRT.
Studies show that the use of HRT in younger women or early postmenopausal women has a beneficial effect on the cardiovascular system, reducing coronary disease and all-cause mortality.
To dig a little deeper, the main theme of The Lancet series is that the perimenopause and menopause is a time of accelerating cardiometabolic disease risk. There is an important opportunity to raise awareness of symptoms and potential health consequences, adopt healthy behaviours to reduce cardiovascular disease risk factors, and implement screening and preventive strategies to reduce the risk of chronic cardiometabolic diseases that can occur in later life.
And, as the editorial states, healthcare for women approaching menopause, at menopause, and after menopause must be improved and the unmet need could not be larger.
The first article in the series has a focus on cardiometabolic changes in women at midlife. It describes menopause as a “turning point”, where the risk of cardiovascular disease increases.
The paper then turns to the issue of non-hormonal management, which the authors describe as the “cornerstone” of prevention of cardiovascular disease. This is not a controversial claim, as healthy diet, exercise and weight control are obviously crucial to health in general, as well as menopause management and disease prevention. Yet these things will not adequately address oestrogen deficiency, which is the hallmark of menopause transition.
What we are calling for is a holistic approach: one that stresses the importance of diet, exercise and weight control as a cornerstone of health while at the same time, stressing the importance of treating oestrogen deficiency.
This is the theme of the second paper in the series, which focuses on hormone therapy as an important option, both for quality of life and reducing mortality.
Lobo and Gompel’s article points out that many of the health issues associated with the experience of menopause transition — such as depression and sleep deprivation — constitute risk factors for cardiovascular disease. They go on to describe how early initiation of hormonal therapy has a substantial beneficial role in symptom control, which is one important aspect of improving quality of life.
Another important aspect is the preventative role of HRT with regard to major chronic diseases. On this, the authors’ analysis of the data is emphatic. Hormone therapy reduces coronary and all-cause mortality. It has a role in the prevention of osteoporosis and is somewhat protective against degenerative osteoarthritis. HRT is also likely to drive the reduction of new-onset diabetes in postmenopausal women; and offers protection against developing Alzheimer’s disease. And while early initiation is key, hormone therapy is described as an intervention that could have “long-lasting consequences in terms of morbidity, mortality, and quality of life”.
These recent articles, along with the body of research behind it, could and should transform medical and social attitudes about HRT.
We hope that it will finally rid HRT of the myths and misinformation that has existed since 2002 in the wake of the initial findings of the Women’s Health Initiative, which suggested an increased risk of breast cancer and blood clots. These findings were naively interpreted and sensationally reported.
Lobo and Gompel’s article also deals with the issue of risk, something that has often been wrongly associated with HRT. They argue that, apart from venous thrombosis risk with oral oestrogen, there is clearly more benefit than harm. They also point out that data on the risk of breast cancer has been largely based on the use of synthetic progestogens; and that risk could be alleviated with the use of natural micronised progesterone or dydrogesterone.
Physical inactivity, alcohol consumption and obesity present far greater risk factors for breast cancer.
The risks of HRT, then, are negligible for most women and it is high time that this is acknowledged and that it feeds through to medical practice. This is not to deny that research should rightly continue; and any contraindications should be taken seriously. That is what good science and medicine is about.
However, the evidence presented in these articles is compelling. Non-hormonal management may well have been the cornerstone of prevention of cardiovascular disease but, for perimenopausal and menopausal women, hormone therapy should now be considered the linchpin of quality of life, symptom control and disease prevention. As Lobo and Gompel point out, data on lifestyle efforts shows a “quite modest” mortality risk reduction of 12-14 per cent whereas, with menopausal hormone therapy, a consistent 30 per cent decrease in all-cause mortality has been found.
In addition, they add, menopausal hormone therapy affords protection from osteoporosis, reduces menopausal symptoms, and improves quality of life.
All of this suggests that, while HRT is always a personal choice, it is one that should be offered early. Indeed, it should be recommended by healthcare practitioners given its key role in alleviating menopausal symptoms, preventing disease and promoting quality of life. We now have the knowledge and the capacity to reduce the health burden on women in midlife and beyond. To fail to act on that knowledge would be wholly unethical, given the impact that menopause can have on women’s lives and, more bluntly, the preventable disease and death that would continue to follow.
- Dr Richard Hull is a lecturer in philosophy at NUI Galway, Dr Louise Newson is a GP, Menopause specialist and Chair of the Newson Health Menopause Society.