Dr Alison Wright, spokesperson for the RCOG, writes...
Women need clear, evidence-based information to break through the conflicts of opinion and confusion about the menopause. This is all about informed choice.
The menopause, sometimes known as ‘the change’, refers to the biological stage in a woman’s life when her periods stop and her ovarian function reduces. This usually occurs between the ages of 45 and 55, but it can occur in younger women.
Today’s launch of the NICE guideline is an important step forward in our understanding of the diagnosis and management of the menopause. Leading experts in the field have examined the existing evidence to provide information and advice which we hope will enable women to better understand the menopause and to make informed choices about how to manage it.
This new guideline also aims to better equip healthcare professionals, such as GPs, nurses and gynaecologists, to provide women with evidence-based information about the risks and benefits of different treatment options.
Every woman experiences the menopause differently. Symptoms can last from a few months to several years and up to 80% of women experience physical and/or emotional symptoms during this time. These can include; hot flushes, night sweats, tiredness, sleep disturbance, joint and muscle ache, mood swings and depression, forgetfulness or lack of concentration, vaginal dryness and loss of interest in having sex.
With life expectancy now at 83.2 years, many women are living in this post-menopausal phase for one third, or even half their life, and their symptoms can have a major impact on their health, work, relationships and quality of life.
We know that many women go through the menopause, managing their symptoms without wishing to take treatment. Others choose to use hormone replacement therapy (HRT) or non-hormonal treatments such as exercise, cognitive behavioural therapy, relaxation techniques, black cohosh, isoflavones (plant estrogens) or St John’s wort.
HRT is controversial and for years, we have seen its use go in and out of vogue, which does not help women seeking guidance about whether or not to take it.
Studies looking at risks and benefits of HRT are ongoing. However, this guideline has focussed mainly on the available evidence and research regarding the risks of breast cancer, heart disease, stroke and bone health in women aged between 50 and 59, associated with HRT.
The increased risk of breast cancer associated with HRT has been well documented in the past, and is reiterated in this guideline. To give some perspective, breast cancer is the most common cancer in the UK and approximately 22 in every 1,000 women in the general population will suffer from breast cancer over a period of 7.5 years. For women taking oestrogen and progesterone HRT, we expect to see around five extra cases of breast cancer over the same time period. Oestrogen only treatment, which is given to women who have had a hysterectomy, shows four fewer cancers in same timeframe. It appears to be the progesterone which has the effect of increasing disease. This risk is related to the treatment duration and reduces after stopping HRT.
Heart health and stroke risk are other areas that are widely debated. Looking at the evidence within the NICE guideline, HRT does not increase heart disease when started in women under 60 years of age and there is no associated increased risk of dying from heart disease. The numbers of women affected by stroke between 50 and 59 are small – around 11 per 1000 women over 7.5 years, this risk is slightly elevated in women taking oestrogen and progesterone HRT, with an extra 6 more cases over the same time period. However, both heart disease and stroke risk are dependent on other lifestyle factors and medical history.
A significant benefit of HRT, according to the evidence, is that it can improve bone health and reduce the risk of osteoporosis and fractures in later life.
This guideline recognises that HRT is an effective treatment for menopausal symptoms, particularly with the management of hot flushes. However, the risks and benefits are different for each woman, depending on her own medical history, her family history and her menopausal symptoms. To take or not to take HRT, or other treatments for menopausal symptoms, is an individual choice.
It’s also important to remember that lifestyle factors such as obesity and smoking play a large role in a woman’s short and long-term health and we encourage all women, no matter what their age, to maintain a balanced diet, engage in regular physical activity and refrain from smoking. This advice is particularly relevant for menopausal women, as lifestyle factors can impact on the severity and length of menopausal symptoms.
HRT is just a small component of the treatment of menopause which depends on a clear understanding of an individual woman’s circumstances. Women deserve access to the highest quality information and advice. We hope this new guidance will educate healthcare professionals about the diagnosis and management of the menopause and empower women themselves to make properly informed choices.
Alison is also a clinical representative on RCOG’s Women’s Network – which is made up of lay members who work alongside clinicians and health professionals to provide a patient’s perspective to many aspects of RCOG activities.