Millions of women in Ireland and the UK are going through perimenopause and menopause.
It is a health issue that as a society we can no longer afford to ignore; not only in how we help women relieve their symptoms, but also in how we can protect their health.
In recent years, more attention has been paid to the fact that perimenopause (the period immediately before menopause) can trigger many health problems. The list of potential 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 libido.
Each 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 disease risk. Importantly, research also suggests that many of these problems can be avoided or reduced by taking HRT in the ‘critical window’ of the early stages of menopause and also during perimenopause.
It could, and should, revolutionize our attitudes towards HRT, which have been overshadowed by misinterpretation of data and alarmist headlines that have led to ill-informed decisions and a drop in the number of women taking HRT in the years 2000.
Simply put, HRT is more than just a “cure” for menopausal symptoms and many more women should consider taking it.
The Lancet, one of the oldest and most respected medical journals in the world, recently published two articles and an editorial on menopause. One of these articles argued that HRT should be considered an important preventive treatment that can improve the quality and length of life. We believe this, coupled with an increasingly strong body of research to support such a claim, should be a game-changer for menopause care and, more specifically, women’s lives.
Why? Because women unnecessarily succumb to disease, die earlier, and have an overall lower quality of life. Of course, some women don’t have many or any of the symptoms listed above, so don’t see the need for HRT.
However, research suggests that these women are wrong; and that these women are risking their cardiovascular health, bone health, and possibly their neurological health by avoiding HRT. They too, as such, should give serious thought to the preventive benefits of HRT.
Studies show that HRT use in younger women or early menopausal 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 for cardiometabolic disease. There is a significant opportunity to raise awareness of symptoms and potential health consequences, adopt healthy behaviors to reduce risk factors for cardiovascular disease, and implement screening and prevention strategies to reduce disease risk chronic cardiometabolic disorders that can occur later in life.
And, as the editorial states, health care for women approaching menopause, in menopause and after menopause needs to be improved and the unmet needs couldn’t be greater.
The first article in the series focuses on cardiometabolic changes in middle-aged women. He describes menopause as a “turning point,” where the risk of cardiovascular disease increases.
The article then addresses the issue of non-hormonal management, which the authors describe as the “cornerstone” of cardiovascular disease prevention. This is not a controversial claim, as healthy diet, exercise, and weight control are obviously essential for overall health, as well as for managing menopause and preventing disease. Yet these things will not adequately address estrogen deficiency, which is the hallmark of the menopausal transition.
What we are calling for is a holistic approach: an approach that emphasizes the importance of diet, exercise and weight control as the cornerstone of health while emphasizing the importance of treating deficiency in estrogen.
This is the theme of the second article in the series, which emphasizes hormone therapy as an important option, both for quality of life and for reducing mortality.
Lobo and Gompel’s article points out that many of the health problems associated with experiencing the menopausal transition — such as depression and sleep deprivation — are risk factors for cardiovascular disease. They then 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 major chronic diseases. On this point, the analysis of the data by the authors is categorical. Hormone therapy reduces coronary and all-cause mortality. It has a role in preventing osteoporosis and is somewhat protective against degenerative osteoarthritis. HRT may also reduce new onset diabetes in postmenopausal women; and provides protection against the development of Alzheimer’s disease. And while early initiation is essential, hormone therapy is described as an intervention that could have “lasting consequences in terms of morbidity, mortality and quality of life”.
These recent articles, and the body of research behind them, could and should transform medical and social attitudes towards HRT.
We hope it will finally rid HRT of the myths and misinformation that have existed since 2002 following early findings from the Women’s Health Initiative, which suggested an increased risk of breast cancer and blood clots. These results have been naively interpreted and sensationally reported.
Lobo and Gompel’s article also addresses the issue of risk, something that has often been wrongly associated with HRT. They argue that, aside from the risk of venous thrombosis with oral estrogens, there are clearly more benefits than harms. They also point out that data on the risk of breast cancer are largely based on the use of synthetic progestins; and this risk could be mitigated by the use of micronized natural progesterone or dydrogesterone.
Physical inactivity, alcohol consumption and obesity are much more important risk factors for breast cancer.
The risks of HRT are therefore negligible for most women and it is high time that this was recognized and reflected in medical practice. This is not to deny that research should rightly continue; and any contraindication should be taken seriously. This is what science and medicine are all about.
However, the evidence presented in these articles is compelling. Non-hormonal management may have been the cornerstone of cardiovascular disease prevention, but for perimenopausal and postmenopausal women, hormone therapy should now be seen as the cornerstone of quality of life, control of symptoms and disease prevention. As Lobo and Gompel point out, data on lifestyle efforts show a “fairly modest” reduction in mortality risk of 12-14%, whereas with menopausal hormone therapy a steady 30% decrease all-cause mortality was observed.
Additionally, they add, menopausal hormone therapy provides 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. Indeed, it should be recommended by healthcare professionals given its key role in relieving menopausal symptoms, preventing disease and promoting quality of life. We now have the knowledge and ability to reduce the health burden of 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 bluntly, the preventable illnesses and deaths that would continue to ensue.
– Dr Richard Hull is a Lecturer in Philosophy at NUI Galway, Dr Louise Newson is a general practitioner, menopause specialist and president of the Newson Health Menopause Society.
Hormone therapy is much more than a “cure for menopause”. More women should consider taking it