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New Menopause Guidelines Released in Response to HRT Shortages

In response to concerns about recent shortages of hormone replacement therapy (HRT), major national bodies have produced a new set of evidence-based recommendations on menopause management.

They advise that rather than a "one size fits all” approach, clinicians consider the individual needs of each woman, with the risks and benefits of hormonal therapies, as well as lifestyle choices, assessed in the context of age, cardiovascular health, cancer status, and body weight.

The joint position statement from the British Menopause Society (BMS), Royal College of Obstetricians and Gynaecologists (RCOG), and the Society for Endocrinology (SfE), published in Post Reproductive Health, aims to provide "clear, expert and evidence-based consensus on best practice for menopause care".

New Guidelines Address 'a Plethora of Misinformation' About Menopause

It was also prompted by "a plethora of misinformation about menopause in the mainstream media", according to representatives of each organisation writing in an accompanying editorial co-published in Clinical Endocrinology.

Examples of misinformation included:

  • HRT in the prevention of dementia - the current body of evidence does not support this
  • Testosterone replacement to improve cognitive function, musculoskeletal health, bone density or fracture prevention - testosterone supplementation should not be offered for these indications, though it may benefit menopausal women with low sexual desire
  • A history of breast cancer as a contraindication to systemic HRT – although this is generally true, in exceptional cases, and after discussions with the breast oncology team, HRT may be offered for severe symptoms if other options are not effective

Individualised Approach Recommended

As well as correcting these media myths, the position statement’s recommendations included:

  • All women should be able to access individualised advice on how to optimise their menopause transition with reference to lifestyle and diet modification as well as interventions including HRT
  • Women should be advised that a healthy lifestyle can improve symptoms, including a healthy diet low in saturated fat and salt and rich in calcium and vitamin D, along with regular exercise, avoiding smoking, and moderating alcohol and caffeine intake
  • Women who don’t wish to take or have contraindications to HRT could consider other options such as cognitive behavioural therapy
  • Decisions about HRT, its dose and duration should be made on an individualised basis after discussing benefits and risks, including symptom control, quality of life, bone and cardiovascular benefits. No arbitrary limits should be set on age or duration of HRT intake
  • Whilst HRT is effective for prevention and treatment of osteoporosis, bisphosphonates should be considered the first-line option for most patients
  • However, HRT is the first-line option for osteoporosis in women with premature ovarian insufficiency or early menopause, in whom HRT is unlikely to increase risk of breast cancer under age 50. Such women should be advised to take HRT at least until the average age of menopause
  • Current evidence suggests that oestrogen-only HRT is associated with a lower risk of breast cancer than combined HRT; however women with a uterus require progestogen to minimise the risk of endometrial cancer associated with unopposed oestrogen
  • Transdermal oestradiol carries a lower risk of venous thrombosis or stroke than oral administration and should be considered the route of choice in women at risk
  • Vaginal oestrogen preparations for genitourinary symptoms can be taken for as long as required with no need for combination with systemic progestogen

Both the position statement and the editorial stressed that: "HRT should not be used without a clear indication and should not be used for the sole purpose of disease prevention. Menopause is a life stage and does not represent a deficiency state."

Access to HRT Limited by Shortages

Introducing the position statement, Dr Edward Morris, joint editorial author and president of the RCOG, said: "It's clearly been a really distressing time for many women who have tried to access their regular form of HRT and not been able to as a result of these shortages.

"The aim of this statement is to provide clear recommendations of best practice for healthcare professionals caring for women and people of all ages who have menopausal symptoms. All women will experience the menopause in different ways and that's why it’s important they are provided with tailored care that's right for them."

Lead author Haitham Hamoda, consultant gynaecologist at King’s College Hospital, London and chairman of the BMS, said: "Whilst women can access much information on the internet and social media, there unfortunately remains some misinformation. The importance of applying a holistic and individualised approach in the care of women going through the menopause transition was recognised in the NICE guidance in 2015, as well as other national and international guidance documents. It is essential that women are made aware that help and support is available to them and are provided with access to accurate information."

Co-author Professor Stephanie Baldeweg, consultant endocrinologist at University College London and SfE clinical committee chair said: "In recent years, the mainstream media has provoked much positive discussion over what treatments are available and what more could be done to support women going through the menopause. Some reports and headlines have been conflicting, so guidance from independent expert governing bodies, through careful consideration of peer reviewed data from a wide range of high quality sources, is very much needed to empower patients, doctors, practitioners and women to make informed choices."

Lead Image Credits: Peter Dazeley/Getty Images


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