Guidelines,guidelines,guidelines!

Over the last year, four important guidelines^1–4 have been published which should lead to some consistency around information being provided for women, along with raised awareness of the importance of menopause and post-reproductive health. However, there are two areas which deserve further attention: while the overall messages from the guidelines are similar, there are some differences which may cause further confusion, and secondly, can we be sure that the information is filtering down to healthcare professionals out with specialist societies, and ultimately to women?

All the guidelines consider many aspects of menopause and treatment options, with consistency around the importance of information provision, the stages of the menopause, diet and lifestyle advice, and the need for individualisation. A key focus for all is the role of hormone replacement therapy, yet even the name provides some difference with NICE referring to Hormone Replacement Therapy (HRT) and the others all referring to menopausal hormone therapy (MHT).

Whatever the name, all the guidelines have reviewed previous studies regarding benefits and risks in detail, and we can now be completely confident that the shocking findings from the Women’s Health Initiative trial which led to a massive drop in prescribing of hormone therapy, can be considered in perspective and not viewed in isolation. Overall, the consistent message is that HRT/MHT is the most effective treatment currently available for menopausal vasomotor symptoms and that the benefits generally exceed risks for women who start treatment before the age of 60 or within 10 years of the menopause.

Regarding other symptoms of the menopause, while NICE recommends offering HRT for hormonally related mood changes, other guidelines suggest that MHT may improve symptoms such as joint and muscle pains, mood swings and disturbed sleep. All guidelines though agree that hormone therapy is effective for genitourinary syndrome of menopause (GSM) and that in the absence of vasomotor symptoms, GSM is best treated by vaginal estrogen.

Where some further differences between the guidelines exist are in relation to the long-term health benefits and the role of HRT/MHT in primary prevention. Compared to NICE and the Endocrine Society guideline in particular, (which states that there is no justification for MHT to prevent coronary heart disease (CHD), breast cancer or dementia), the International Menopause Society ³ recommends that:

MHT is the most appropriate therapy for fracture prevention in early menopause.

Meanwhile, the Revised Global Consensus Statement on Menopausal Hormone Therapy ⁴ agrees that MHT is effective in the prevention of bone loss and can be initiated in women under age of 60 in women at risk of fracture or osteoporosis, but takes a middle road regarding cardiovascular prevention, stating that standard dose estrogen MHT may decrease the risk of myocardial infarction and all cause mortality when started in women under age 60 or within 10 years of the menopause.

Whether or not HRT/MHT will ever be recommended for primary prevention of osteoporosis, cardiovascular disease or dementia in women who do not require treatment for vasomotor symptoms is still unclear, but the combined effect of all these guidelines is that women and healthcare professionals can be reassured that HRT/MHT is an effective option for control of menopausal symptoms with minimal risks.

Guidelines are only useful if the key messages are widely read, understood and applied by both healthcare professionals and women themselves. The NICE guideline published in November 2015 received much media attention, yet a recent Ipsos Mori survey of a nationally representative sample of 1200 women aged 45–65 across Great Britain carried out on behalf of the British Menopause Society, showed that only 3% of women had heard of the NICE guideline. Further, despite the publicity around publication encouraging women to access information and seek help for symptoms, one in two women in the survey who experienced symptoms had not consulted a healthcare professional. This is despite the fact that women reported several symptoms which were often worse than expected and had an impact on home life, work, social life and sex life.

It is clear that much work is required to spread the trusted, authoritative guidance to healthcare professionals outside specialist societies so that women can be given consistent information, and to women so that they can have truly informed discussions.