GUEST EDITORIAL
Menopausal Hormone Therapy and Quality of Life: Too Many Pyjamas Robert L. Reid, MD, FRCSC,1 Michel P. Fortier, MD, FRCSC2 Department of Obstetrics and Gynaecology, Queen’s University, Kingston ON
1
Department of Obstetrics and Gynecology, Université Laval, Québec QC
2
T
he updated SOGC Clinical Practice Guidelines “Managing Menopause” and “Osteoporosis in Menopause” have recently been released on the SOGC website.1,2 We wish to thank those who contributed their time and expertise to analyze and synthesize the latest evidence into a practical document with evidence-based recommendations for care of the menopausal woman.
women with hot flashes who received MHT showed significant improvement in vasomotor symptoms, sleep, anxiety and fears, and memory and concentration. MHT significantly relieved exhaustion, irritability, edema, joint and muscle pain, and vaginal dryness. Sexual well-being showed no clear improvement when women took MHT; however, this is not surprising given the complexity of the issue.
One of us recently asked a patient how things were going with her new hormone therapy prescription. She replied “I have too many pyjamas.” When she was asked to explain, her reply was both amusing and saddening. She pointed out that two months ago, before starting the hormone therapy, her night sweats had been so bad that she had kept numerous pairs of pyjamas at the bedside so that when she soaked through them every couple of hours she had a fresh set to hand. Since starting hormones she had actually worn a pair of socks to bed to keep her feet warm, and she had been sleeping through the night. Now she had too many pyjamas. The sad side to this story is that she had spent two years trying various alternative therapies for her night sweats without finding relief. Only recently had she moved and found a new family physician who had made the referral for consideration of hormone therapy.
With increasing numbers of women entering the menopause, and their increased involvement in the work force (many at executive levels), the impact of reduced HRQoL can hardly be overstated. We need to use the tools at our disposal to minimize the adverse impact of menopause-related symptoms. In contrast to the many alternative therapies that have been marketed in the past decade, MHT has been shown in well-designed clinical trials to be highly effective for relief of vasomotor symptoms as well as a variety of other manifestations of menopause.
Quality of life for many menopausal women has surely suffered in the past decade, as the confusing and often contradictory literature has left health care providers uncertain about the safety of menopausal hormone therapy (MHT). A recent randomized placebo controlled trial from Scandinavia evaluated the effects of MHT on health-related quality of life (HRQoL) in women with and without hot flashes.3 The findings are informative. At baseline, women with hot flashes had significantly more factors associated with poor HRQoL, including poor sleep, somatic symptoms, anxiety and fears, poor memory and concentration, and sexual dissatisfaction. After six months of MHT, only
We have learned that the effects of hormones are complex and may differ depending on dosage, formulation, route of delivery, time of initiation after menopause, and age of the woman.6 There is increasing evidence that the first decade after onset of menopause may be the “window of opportunity” for initiation of MHT to minimize risk and maximize long-term benefits.8
We are now more than a decade past the first publications from the Women’s Health Initiative (WHI),4,5 and we have had more than enough time to analyze and reanalyze the data from that landmark investigation. It is time to summarize what we have learned and where the gaps in our knowledge remain.6,7
We have also learned that the benefits of MHT outweigh the risks for most recently menopausal women. Although J Obstet Gynaecol Can 2014;36(11):953–954
NOVEMBER JOGC NOVEMBRE 2014 l 953
Guest Editorial
fear of breast cancer remains a common reason for women and their health care providers to hesitate when considering MHT, the WHI revealed that first-time users had no increased risk of breast cancer during the 5.6 years of the combined estrogen-progestin therapy trial and that any small increase in risk with longer term use returned to normal shortly after MHT was stopped.6 The impact of estrogen alone on breast cancer risk seems to be less than that of combined estrogen-progestin, and in the WHI there was no increase in the rate of breast cancer after eight years of estrogen-only therapy.9 In the new guidelines, the SOGC has taken a conservative approach, emphasizing the importance of a healthy lifestyle, acknowledging the role, benefits, and risks of MHT, and recommending against the use of MHT for prevention of chronic diseases. In some circumstances, such as in women with persistent distressing vasomotor symptoms or in women with a high risk for osteoporosis, the extended use of MHT may be appropriate after discussion of the risks and benefits.10 The role and safety of local (intravaginal) estrogen is emphasized when women complain of genitourinary syndrome of menopause. 1,2
The updated guidelines provide summaries of the latest scientific evidence to allow health care providers to address the needs of a diverse menopausal population. Women entering the menopause experience an array of symptoms that can vary from tolerable to extremely disruptive. Information is critical to personal decisionmaking, and women will collect this from friends and acquaintances as well as from radio, television, books, magazines, and the Internet. It is important that health care providers stay informed so that they can assess each woman and her situation optimally and provide accurate and up-to-date answers to her questions. Risk assessment is important because a woman’s personal risk for certain conditions, such as osteoporosis, cardiovascular disease, cancer, and genitourinary syndrome of menopause, may not be apparent and must be considered in any decisionmaking.
954 l NOVEMBER JOGC NOVEMBRE 2014
Ultimately it is the responsibility of health care providers to evaluate each woman’s needs, to offer informed advice, and to respect her choice about how best to deal with her specific concerns. We must remember that one size does not fit all. REFERENCES 1. Reid R, Abrahamson, Blake J, Desindes S, Dodin S, Johnston S, et al.; SOGC Menopause and Osteoporosis Working Group. Managing Menopause. SOGC Clinical Practice Guideline No. 311, September 2014. J Obstet Gynaecol Can 2014;36(9 eSuppl A):S1–S80. 2. Khan A, Fortier M; SOGC Menopause and Osteoporosis Working Group. Osteoporosis in Menopause. SOGC Clinical Practice Guideline No. 312, September 2014. J Obstet Gynaecol Can 2014;36(9 eSuppl C):S1–S15. 3. Savolainen-Peltonen H, Hautamaki H, Tuomikoski P, Ylikorkala O, Mikkola T. Health–related quality of life in women with or without hot flashes: a randomized placebo-controlled trial with hormone therapy. Menopause 2013; 21(7):732–9. 4. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321–33. 5. Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA 2004;291:1701–12. 6. Manson JE, Chlebowski RT, Stefanick ML, Aragaki AK, Rossouw JE, Prentice RL, et al. Menopausal hormone therapy and health outcomes during the intervention and extended post-stopping phases of the Women’s Health Initiative Randomized Trials. JAMA 2013;310(13):1353–68. 7. Lobo RA. Where are we 10 years after the Women’s Health Initiative? J Clin Endocrinol Metab 2013;98:1771–80. 8. Clarkson TB, Melendez GC, Appt SE. Timing hypothesis for postmenopausal hormone therapy: its origin, current status and future. Menopause 2013;20:342–53. 9. Anderson GL, Chlebowski RT, Aragaki AK, Kuller LH, Manson JE, Gass M, et al. Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women’s Health Initiative randomised placebocontrolled trial. Lancet Oncology 2012;13:476–86. 10. Reid RL. Stop: enforcing a 5-year rule for menopausal hormone replacement therapy. Start: individualizing therapy to optimize health and quality of life. OBG Manag 2013;25:24–8. Available at: http://www.obgmanagement.com/ the-latest/past-issues-list/baa3997bb3fbc2e587b0b62e126e9647.html?tx_ gia%5Bfreq%5D=monthly&tx_gia[start]=201312. Accessed August 26, 2014.
Menopausal Hormone Therapy and Quality of Life: Too Many Pyjamas Robert L. Reid, MD, FRCSC,1 Michel P. Fortier, MD, FRCSC2 Department of Obstetrics and Gynaecology, Queen’s University, Kingston ON
1
Department of Obstetrics and Gynecology, Université Laval, Québec QC
2
T
he updated SOGC Clinical Practice Guidelines “Managing Menopause” and “Osteoporosis in Menopause” have recently been released on the SOGC website.1,2 We wish to thank those who contributed their time and expertise to analyze and synthesize the latest evidence into a practical document with evidence-based recommendations for care of the menopausal woman.
women with hot flashes who received MHT showed significant improvement in vasomotor symptoms, sleep, anxiety and fears, and memory and concentration. MHT significantly relieved exhaustion, irritability, edema, joint and muscle pain, and vaginal dryness. Sexual well-being showed no clear improvement when women took MHT; however, this is not surprising given the complexity of the issue.
One of us recently asked a patient how things were going with her new hormone therapy prescription. She replied “I have too many pyjamas.” When she was asked to explain, her reply was both amusing and saddening. She pointed out that two months ago, before starting the hormone therapy, her night sweats had been so bad that she had kept numerous pairs of pyjamas at the bedside so that when she soaked through them every couple of hours she had a fresh set to hand. Since starting hormones she had actually worn a pair of socks to bed to keep her feet warm, and she had been sleeping through the night. Now she had too many pyjamas. The sad side to this story is that she had spent two years trying various alternative therapies for her night sweats without finding relief. Only recently had she moved and found a new family physician who had made the referral for consideration of hormone therapy.
With increasing numbers of women entering the menopause, and their increased involvement in the work force (many at executive levels), the impact of reduced HRQoL can hardly be overstated. We need to use the tools at our disposal to minimize the adverse impact of menopause-related symptoms. In contrast to the many alternative therapies that have been marketed in the past decade, MHT has been shown in well-designed clinical trials to be highly effective for relief of vasomotor symptoms as well as a variety of other manifestations of menopause.
Quality of life for many menopausal women has surely suffered in the past decade, as the confusing and often contradictory literature has left health care providers uncertain about the safety of menopausal hormone therapy (MHT). A recent randomized placebo controlled trial from Scandinavia evaluated the effects of MHT on health-related quality of life (HRQoL) in women with and without hot flashes.3 The findings are informative. At baseline, women with hot flashes had significantly more factors associated with poor HRQoL, including poor sleep, somatic symptoms, anxiety and fears, poor memory and concentration, and sexual dissatisfaction. After six months of MHT, only
We have learned that the effects of hormones are complex and may differ depending on dosage, formulation, route of delivery, time of initiation after menopause, and age of the woman.6 There is increasing evidence that the first decade after onset of menopause may be the “window of opportunity” for initiation of MHT to minimize risk and maximize long-term benefits.8
We are now more than a decade past the first publications from the Women’s Health Initiative (WHI),4,5 and we have had more than enough time to analyze and reanalyze the data from that landmark investigation. It is time to summarize what we have learned and where the gaps in our knowledge remain.6,7
We have also learned that the benefits of MHT outweigh the risks for most recently menopausal women. Although J Obstet Gynaecol Can 2014;36(11):953–954
NOVEMBER JOGC NOVEMBRE 2014 l 953
Guest Editorial
fear of breast cancer remains a common reason for women and their health care providers to hesitate when considering MHT, the WHI revealed that first-time users had no increased risk of breast cancer during the 5.6 years of the combined estrogen-progestin therapy trial and that any small increase in risk with longer term use returned to normal shortly after MHT was stopped.6 The impact of estrogen alone on breast cancer risk seems to be less than that of combined estrogen-progestin, and in the WHI there was no increase in the rate of breast cancer after eight years of estrogen-only therapy.9 In the new guidelines, the SOGC has taken a conservative approach, emphasizing the importance of a healthy lifestyle, acknowledging the role, benefits, and risks of MHT, and recommending against the use of MHT for prevention of chronic diseases. In some circumstances, such as in women with persistent distressing vasomotor symptoms or in women with a high risk for osteoporosis, the extended use of MHT may be appropriate after discussion of the risks and benefits.10 The role and safety of local (intravaginal) estrogen is emphasized when women complain of genitourinary syndrome of menopause. 1,2
The updated guidelines provide summaries of the latest scientific evidence to allow health care providers to address the needs of a diverse menopausal population. Women entering the menopause experience an array of symptoms that can vary from tolerable to extremely disruptive. Information is critical to personal decisionmaking, and women will collect this from friends and acquaintances as well as from radio, television, books, magazines, and the Internet. It is important that health care providers stay informed so that they can assess each woman and her situation optimally and provide accurate and up-to-date answers to her questions. Risk assessment is important because a woman’s personal risk for certain conditions, such as osteoporosis, cardiovascular disease, cancer, and genitourinary syndrome of menopause, may not be apparent and must be considered in any decisionmaking.
954 l NOVEMBER JOGC NOVEMBRE 2014
Ultimately it is the responsibility of health care providers to evaluate each woman’s needs, to offer informed advice, and to respect her choice about how best to deal with her specific concerns. We must remember that one size does not fit all. REFERENCES 1. Reid R, Abrahamson, Blake J, Desindes S, Dodin S, Johnston S, et al.; SOGC Menopause and Osteoporosis Working Group. Managing Menopause. SOGC Clinical Practice Guideline No. 311, September 2014. J Obstet Gynaecol Can 2014;36(9 eSuppl A):S1–S80. 2. Khan A, Fortier M; SOGC Menopause and Osteoporosis Working Group. Osteoporosis in Menopause. SOGC Clinical Practice Guideline No. 312, September 2014. J Obstet Gynaecol Can 2014;36(9 eSuppl C):S1–S15. 3. Savolainen-Peltonen H, Hautamaki H, Tuomikoski P, Ylikorkala O, Mikkola T. Health–related quality of life in women with or without hot flashes: a randomized placebo-controlled trial with hormone therapy. Menopause 2013; 21(7):732–9. 4. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321–33. 5. Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA 2004;291:1701–12. 6. Manson JE, Chlebowski RT, Stefanick ML, Aragaki AK, Rossouw JE, Prentice RL, et al. Menopausal hormone therapy and health outcomes during the intervention and extended post-stopping phases of the Women’s Health Initiative Randomized Trials. JAMA 2013;310(13):1353–68. 7. Lobo RA. Where are we 10 years after the Women’s Health Initiative? J Clin Endocrinol Metab 2013;98:1771–80. 8. Clarkson TB, Melendez GC, Appt SE. Timing hypothesis for postmenopausal hormone therapy: its origin, current status and future. Menopause 2013;20:342–53. 9. Anderson GL, Chlebowski RT, Aragaki AK, Kuller LH, Manson JE, Gass M, et al. Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women’s Health Initiative randomised placebocontrolled trial. Lancet Oncology 2012;13:476–86. 10. Reid RL. Stop: enforcing a 5-year rule for menopausal hormone replacement therapy. Start: individualizing therapy to optimize health and quality of life. OBG Manag 2013;25:24–8. Available at: http://www.obgmanagement.com/ the-latest/past-issues-list/baa3997bb3fbc2e587b0b62e126e9647.html?tx_ gia%5Bfreq%5D=monthly&tx_gia[start]=201312. Accessed August 26, 2014.
