For most symptomatic women, the benefits of menopausal hormone therapy (MHT) outweigh the risks. Yet many GPs remain reluctant to prescribe it. Is it time to reconsider?
As an expert in the field, Jean Hailes for Women’s Health endocrinologist Dr Sonia Davison understands that consultations on menopause are complex. Women present with different symptoms and needs. Some will be distressed by their condition and may be emotional. A comprehensive medical history will be required followed by a considered and considerate discussion on therapies that might be able to help.
This can be a challenge for most clinicians, but perhaps even more so for GPs who have to manage these complicated discussions in much tighter consultation times.
Compounding the problems for at least some GPs is the lack of specialised knowledge around menopausal hormone therapy (MHT). Some consigned it to the too-hard basket following the release nearly two decades ago of the Women’s Health Initiative (WHI) Study, a randomised controlled trial in the United States that revealed a link between women who used hormone replacement therapy (HRT), as it was then known, and an increased risk of breast cancer.
The alarmist headlines and hysteria that followed saw MHT use plummet across the world. The fear gripped not only women who promptly abandoned the treatment, but also doctors who worried about prescribing a treatment that could adversely affect a patient’s health.
What seemed to be lost to many in the global audience was the fact that the aim of the WHI trial was to test whether taking oestrogen, either alone or with progesterone, after menopause could help prevent heart disease, stroke and cognitive decline in women. It did not address the short-term use of the hormones to manage hot flushes and other symptoms of menopause.
An analysis of the WHI data published in 2017 found that women in the study who used hormone therapy for between five and seven years did not have an increased risk of all-cause, cardiovascular or cancer mortality during the 18-year follow up. And for women in their 50s, there was actually a trend towards a reduced risk of mortality.
These findings, however, caused only a ripple of interest and did little to shift the entrenched negative view on MHT.
Dr Davison, who is president of the Australasian Menopause Society, says that an estimated 13% of women aged around 50 in Australia are on hormone therapy. One of the reasons for its low use is a reluctance by at least some GPs to prescribe it.
“I think for many doctors it’s the fear factor,” she explains. “MHT [in their minds] puts women at higher risk of breast cancer.”
However, the fact is that the international menopause societies and all the expert bodies around the world all agree that the benefits of hormone therapy in healthy women around the time of menopause far outweigh the very small risks.
Dr Sonia Davison, Jean Hailes endocrinologist
Dr Davison believes it can also be challenging for GPs to stay across the burgeoning developments in medicine today. “We are all becoming sub-specialised and GPs are expected to be knowledgeable and up to date on many health topics across many ages, which proves extremely challenging,” she says. “There are so many conditions and medications, some doctors work part-time, some women won’t go to male GPs to discuss women’s health issues, and some male GPs may not see many menopausal women.”
She does believe, however, that it is important for GPs to be up to date on menopausal management. Helpful sources include the Jean Hailes for Women’s Health website – which provides e-learning courses and webinars – as well as the GP and health professional resources available on the Australasian Menopause Society website.
“It’s about knowledge,” says Dr Davison. “It’s about being up to date with the knowledge, understanding the risks and benefits of hormone therapy and other strategies to manage menopause, and if you don’t know, being aware of where to go to get the information.”
There are a number of options available for hormone treatments including tablets, skin patches and gels, and vaginal delivery products. Some hormone products are also body-identical – chemically similar to the oestrogen and progesterone hormones naturally produced in women’s ovaries. Dr Davison says the range of choice makes it difficult for GPs to be familiar with all the products.
She insists, however, that expert guidance is critical for each woman considering MHT. “There are benefits and risks that need to be individualised,” she says. “Hormone therapy can be a highly effective way of treating hot flushes, night sweats, vaginal dryness and other bothersome symptoms.”
A comprehensive medical history is imperative and will include the patient’s family history, her health and her lifestyle. To alleviate her symptoms, the woman might then be taken through the choice of strategies available to her; their risks, their benefits, and those strategies might include hormone therapy.
It may be necessary to make an extended or an additional appointment to cover everything with your patient thoroughly.
Timing is also important. Benefits are maximum if we prescribe hormone therapy around the time menopausal symptoms begin to happen. If we wait for 10 or 15 years, we may have missed the boat.
Dr Sonia Davison, Jean Hailes endocrinologist
For more information on menopause management for health professionals, visit:
Download the Jean Hailes menopause ‘Health professional tool’ here.
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