Millions of women in Ireland and the UK are perimenopausal and menopausal.
It is a health concern that as a society we cannot 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 paid to the fact that perimenopause (the time just before menopause) can trigger numerous health problems. The list of possible problems is long: cardiovascular disease, osteoporosis, type 2 diabetes, neurological symptoms such as hot flashes, sleep disturbances, mood swings and forgetfulness, Alzheimer’s disease, low self-esteem, clinical depression, breathing difficulties, anxiety, fatigue, irregular and/or heavy periods, joint pain, vaginal dryness and decreased sexual desire.
Any of these problems can have a significant impact on quality of life.
Hormone replacement therapy (HRT), which replaces hormones that decline during perimenopause and menopause, can improve these symptoms and reduce the risk of disease. But crucially, the research also suggests 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 perimenopause.
This could and should revolutionize our attitudes towards HRT, which have been overshadowed by the misinterpretation of data and scaremongering headlines that led to ill-informed decisions and a drop in the number of women taking HRT over the years 2000
Simply put, HRT is more than just a “fix” for menopausal 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 on menopause. One such article argued that HRT should be seen as an important preventive therapy that can improve quality and length of life. We believe that this, along with an increasingly strong body of research to support this claim, should be a game changer for menopause care and, more specifically, for women’s lives.
Because? Because women needlessly succumb to disease, die earlier and have a generally lower quality of life. Of course, some women don’t experience many or any of the symptoms listed above, so you don’t see the need to take HRT.
However, research suggests that these women are wrong; and that these women will put their cardiovascular health, bone health, and possibly neurological health at risk by avoiding HRT. They, too, should therefore think seriously about the preventive benefits of HRT.
Studies show that HRT use in younger or early postmenopausal women has a beneficial effect on the cardiovascular system, reducing coronary heart disease and all-cause mortality.
To dig a little deeper, the main theme of The Lancet series is that perimenopause and menopause are a time of accelerated risk of cardiometabolic disease. There is a significant opportunity to raise awareness of symptoms and potential health consequences, adopt healthy behaviors to reduce cardiovascular disease risk factors, and implement screening and preventive strategies to reduce the risk of chronic cardiometabolic diseases that may occur in later life
And, as the editorial states, there is a need for improved health care for perimenopausal, menopausal, and postmenopausal women, and the unmet need could not be greater.
The first article in the series focuses on cardiometabolic changes in middle-aged women. He describes menopause as a “tipping point,” where the risk of cardiovascular disease increases.
The article then turns to the issue of nonhormonal management, which the authors describe as the “cornerstone” of cardiovascular disease prevention. This is not a controversial statement, as a healthy diet, exercise and weight control are obviously crucial to overall health, as well as menopause management and disease prevention. However, these things will not adequately address the estrogen deficiency that is the hallmark of the menopausal transition.
What we’re calling for is a holistic approach—one that emphasizes the importance of diet, exercise, and weight control as the cornerstones of health, while at the same time emphasizing the importance of treating estrogen deficiency.
This is the topic of the second paper in the series, which focuses on hormone therapy as an important option, both for quality of life and for reducing mortality.
Lobo and Gompel’s article notes that many of the health problems associated with the menopausal transition experience, such as depression and sleep deprivation, are risk factors for cardiovascular disease. They go on to describe how early initiation of hormone therapy has a substantial beneficial role in symptom control, which is an important aspect of improving quality of life.
Another important aspect is the preventive role of HRT with respect to the main chronic diseases. In this sense, the analysis of the authors’ data is conclusive. Hormone therapy reduces coronary and all-cause mortality. It plays a role in preventing osteoporosis and is somewhat protective against degenerative osteoarthritis. HRT is also likely to drive reductions in new-onset diabetes in postmenopausal women; and offers protection against the development of 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 papers, along with the body of research behind them, could and should transform medical and social attitudes about HRT.
We hope that it will finally rid HRT of the myths and misinformation that have been around since 2002 following 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 addresses the issue of risk, something that has often been incorrectly associated with HRT. They argue that, aside from the risk of venous thrombosis with oral estrogen, there is clearly more benefit than harm. They also point out that the data on breast cancer risk have been largely based on the use of synthetic progestogens; and this risk could be alleviated with the use of natural micronized progesterone or dydrogesterone.
Physical inactivity, alcohol consumption, and obesity are much greater risk factors for breast cancer.
The risks of HRT are therefore negligible for most women and it is high time that it was recognized and fed into medical practice. This is not to deny that research should rightly continue; and any contraindications should be taken seriously. This is what good science and medicine is all about.
However, the evidence presented in these articles is compelling. Nonhormonal management may have been the cornerstone of cardiovascular disease prevention, but for perimenopausal and menopausal women, hormone therapy should be considered the mainstay of quality of life, symptom control, and disease prevention. As Lobo and Gompel point out, data on lifestyle efforts show a “fairly modest” mortality risk reduction of 12 to 14 percent, while with menopausal hormone therapy, a consistent 30% reduction in all-cause mortality.
In addition, they add, menopausal hormone therapy offers protection against 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. In fact, it should be recommended by health professionals given its key role in alleviating menopausal symptoms, preventing disease and promoting quality of life. We now have the knowledge and ability to reduce the health burden on women in middle age and beyond. Not to act on this knowledge would be totally unethical, given the impact that menopause can have on women’s lives and, more forcefully, the preventable disease and death that would follow.
– Dr Richard Hull is Professor of Philosophy at NUI Galway, Dr. Louise Newson is a GP, menopause specialist and president of the Newson Health Menopause Society.
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