Spotlight on… menopause

Abstract

The last decade has indeed witnessed a surge of high-quality publications, high-profile publicity and awareness campaigns centred around menopause across the medical, social and media spheres. These initiatives have played a pivotal role in destigmatising menopause and fostering open discussions with healthcare providers and policymakers so that women have access to accurate information and appropriate care throughout this life transition. A dedicated Spotlight on menopause could not be timelier, especially during October, dubbed the ‘Month of Menopause’ by the World Health Organization and the International Menopause Society. In 2022, the British Menopause Society (BMS) published a ‘Tool for Clinicians’ addressing the latest available evidence and summarising the 2015 National Institute for Health and Care Excellence (NICE) guidance on the diagnosis and management of menopause. The Tool provided guidance on prescribing bioidentical estradiol and progesterone (uterogestan), the ultra-small (3 mcg) dose of vaginal estradiol inserts, and stated that hormone replacement therapy (HRT) should be offered as first-line treatment for vasomotor symptoms and low mood/anxiety. This should be after discussing its benefits on bone and cardiovascular health, as well as discussing the associated risks. Estrogen alone is associated with little or no change in the risk of breast cancer, while combined HRT can be associated with a small increased risk. The Tool also clarified some misconceptions around HRT, stating that there are no arbitrary limits set on age or duration. In their 2022 review, Kershaw and Jha (TOG 2022;24:12–23) provided updates on defining femal sexual dysfunction as any sexual problem resulting from disorders of desire, arousal, orgasm or sexual pain that causes marked distress and persists for more than 6 months. Despite being a common problem, female sexual dysfunction is frequently underestimated by healthcare practitioners. As gynaecologists, it is imperative that we take the initiative to recognise, address and manage sexual difficulties in our patients. Khanjani and Panay in 2018 (TOG 2019;21:37–42) defined vulvovaginal atrophy as a common, underreported condition associated with decreased vaginal estrogenisation. Non-hormonal therapies, suitable for those unable to use estrogen, range from lubricants and moisturisers to laser treatment. Vaginal estrogen is a commonly used hormonal therapy, however, new, non-hormonal options such as selective estrogen modulators (ospemifene) are considered safer and more effective. Vigneswaran and Hamoda in 2022 (TOG 2022;24:228–41) discussed the physiological declining of androgen levels throughout women's lifespan. Through its effect on the central nervous system, androgen therapy can improve sexual wellbeing, libido and sexual arousal in postmenopausal women in whom estrogen therapy alone has been ineffective. The BMS 2022 Tool advises measuring total, rather than free, testosterone levels prior to treatment to avoid its use in women with naturally high levels. Monitoring by checking total testosterone levels within 2–3 months maintains normal female ranges. Treatment success should be gauged by symptom relief. Current data suggest that off-label transdermal testosterone therapy at physiological doses does not adversely affect lipid profile, blood pressure, blood glucose, or HbA1c levels. However, the long-term safety data is still lacking. Swaminathan et al. in 2023 (TOG 2023;25:229–38) referred to menopausal depression as an entity. Women presenting with menopausal symptoms of hot flushes, night sweats, sleep disturbances and fatigue, along with low mood or new onset depression, are expected to respond better to HRT on its own or in combination with antidepressants. Cognitive behavioural therapy, with or without antidepressants, would seem to be a better choice for women with anxiety and stress related to life events around menopause, and for those where HRT is contraindicated. A multidisciplinary approach with gynaecologists, psychiatrists and specialist nurses is the key to the holistic management of menopause-related psychiatric symptoms. An upcoming episode of the new TOG podcast features lead author Geeta Kumar speaking to TOG Editors further about this topic. Maclaran and Dimitrios (TOG 2019;21:107–16) discussed the impact of early ovarian ageing (EOA) on women who delay childbirth. EOA affects around 10% of women who are frequently asymptomatic. However, continuing follicular loss will result in loss of fertility, menstrual irregularity and, finally, early menopause. The provision of the diagnoses and patient advice is challenging. Addressing fertility preservation and/or family planning alongisde providing suitable psychological counselling can be complex. The long-term health implications, including risk of cardiovascular problems, need to be addressed. Improvements in the success of oocyte freezing have provided a treatment option when EOA is identified early. HRT should be recommended and continued until the average age of the menopause of 51.4 years (Bakour and Williamson; TOG 2015;17:20–8). Evidence from Bregar et al.'s 2014 review (TOG 2014;16:251–8) remains valid in that HRT does not appear to increase the recurrence risk or lower survival rates in endometrial, ovarian, or cervical cancer patients. However, randomised trials suggested that systemic HRT has a potential increase in recurrence risk. Women with estrogen-dependent breast cancer are generally told to avoid hormones. Breast cancer survivors may use low-dose vaginal estrogen if non-hormonal treatments have failed to control symptoms, after a discussion of risks and benefits. Decisions on prescribing HRT to cancer survivors should be personalised, with consideration for the individual's quality of life. Where evidence is limited, a multidisciplinary approach may be necessary and obtaining informed, written consent is recommended (Bakour and Williamson; TOG 2015;17:20–8). Artificial intelligence usage in personalised medicine and pharmacogenomic approaches may help identify women with different dosage requirements based on identification of genetic variants in enzymes involved in hormone metabolism. Dintakurti et al., 2022 (Post Reproductive Health. 2022 Sep;28(3):137–41) investigated the confidence levels of General Practitioners (GPs) in the UK when advising and treating menopausal women and assessed the necessity for additional training. 52% of GPs felt they lacked sufficient support to handle menopausal symptoms effectively, and 77.5% believed that medical school and GP training needed to improve menopause-related education. This study highlighted the demand for better support and training for GPs to ensure that menopausal women receive evidence-based care in the UK. Despite the presence of around 13 million perimenopausal or post-menopausal women in the UK, nearly half of the 32 medical schools did not have a mandatory menopause syllabus for their students as reported by Higher Education Statistics Agency HESA. Consequently, there is a possibility that some medical graduates may enter the profession without any formal education on menopause. Academic gynaecologists globally should play a pivotal role in ensuring that medical students receive comprehensive teaching in menopause before graduating.