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Menopause Live - IMS Updates
InFocus

Date of release: 16 May, 2016

HRT: a change of view?

A recently published original article has described the results of an online survey taken in 2007 and compared the results with those of repeat survey in 2014 [1]. The aim was to illustrate women’s views on HRT, and how they have changed over time, with respect to the availability of reliable information on the safety of, and access to, treatments for the symptoms of the menopause. Whilst the decreased use of HRT, following the unbalanced reporting of the Million Women Study, has been hailed by some as economically beneficial [2], there are others who describe these years as a lost decade, with missed opportunities to prevent and manage chronic diseases. Despite increasing recognition of the flaws in some studies, concerns remain that the information available to women is still insufficient to allow them to make informed decisions regarding treatment. Reassuringly, the results from 2014 indicate that 69.9% of respondents had used or would use HRT, fewer women viewed HRT less favorably, and an increased number of women felt that they were able to make an informed choice regarding HRT. More women are using alternative therapies, yet there has been an increase in those who are unconvinced of their efficacy or safety. It was concluded that pharmacists should provide good-quality evidence on over-the-counter remedies, information from all health professionals must be clear and consistent and, with over one-third accessing their information online, web literacy must be improved.

Comment

It is estimated that within the next 25 years, more than 1 billion women world-wide will be older than 50 years, and approximately 2 million will reach menopause annually in the US alone. Up to 80% of these women will experience adverse symptoms related to menopausal transition, including vasomotor symptoms (VMS) [3]. New data reveal that median total vasomotor duration is 7.4 years, but in some they persist for more than 10 years [4].

The sleep disturbance, fatigue and decreased cognitive function associated with hot flushes and night sweats have been shown to lead not only to a significant reduction in health-related quality of life, but also to an increased use of medical resources, lost productivity at work, as well as increased numbers of sick days [5-7]. This would seem in direct contrast to the data presented in the paper by Roth and colleagues [2].

It is then reassuring that fewer women viewed HRT less favorably, and that 69.9% of respondents had used or would use HRT. However, this figure is down from 74.7% in 2007. One might wonder whether the apparent reluctance to prescribe, and indeed of medical practitioners to recognize the menopause as important, may explain the reduced number of women using HRT despite a decrease in the number of women who view it less favorably.

A study of postmenopausal Spanish women suggested that 78.9% of HRT users were happy with their treatment but, in former or never users of HRT (90 of 270 women surveyed), 43% of women expressed fear of the side-effects as the main reason for not using HRT. Media and negative data from medical journals influenced this attitude in 67% of these women [8].

It is reported here that it is 'promising that the majority of respondents were either undecided or had decided that the media had exaggerated risks associated with HRT'. However, this could be interpreted as nearly half (46.1%) still think that what is reported by the media may in fact be exaggerated, with no significant change from 2007. If one assumes that the women taking this survey are the affluent, well-educated adults purported to be the users of Health Web Science, it suggests that there is still insufficient information for women, or that the information presented is contradictory. Burger and colleagues conclude, in an Evidence-based assessment of the impact of the WHI on women’s health, that the re-analyses of the WHI results have not done enough to reverse the negative media impact of 2002. They argue that untreated women from 2002 have 'lost the best years of their lives' [9].

Unfortunately, evidence from this survey demonstrates that this is still problematic, as there are medical professionals giving no reason for not prescribing HRT, and many are stopping treatment with no reason (88.9%). It is clear that there are many medical professionals who are not up to date.

The publication of the first NICE guideline on Menopause will tackle this head-on. It provides recommendations based on the best available evidence on the support, information and treatments needed to address the symptoms that women experience during the time of the menopause [10]. They have recommended that we adopt an individualized approach at all stages of diagnosis, investigation, and management, and have also stated that HRT is the most effective treatment for the relief of vasomotor symptoms, although other options, including non-pharmacological ones, are available and, for most symptomatic, menopausal women, the benefits of HRT outweigh the risks. Thus, there is now a document, based on the best available evidence, which will enable health professionals to provide their patients with up-to-date information, meaning that women can make an informed choice about their treatment options. Doctors should now feel confident to prescribe HRT when appropriate and, where contraindicated, can provide evidence-based information on alternatives to women who wish it.

Scores of alternative therapies are marketed for menopausal symptoms, often at high costs, and many women are attracted to the safety of ‘natural’ products versus the perceived danger of HRT. This survey has demonstrated that more women are using alternative therapies, but there has also been an increase in the number who are unconvinced of their efficacy or safety. There is evidence that many of the remedies sold over the counter are no better than placebo [11,12], and, as a direct result of a lack of regulation, may even be harmful. The NICE guidelines do acknowledge that there is some evidence that isoflavones and black cohosh may relieve symptoms; however, preparations vary and doctors should be beware of potential interactions with other drugs.

Whilst nearly half (47.8%) still feel that they do not know enough, this is a significant improvement from 2007 (73%). Professionals are still unsure, but with the publication of the NICE guidelines, recommendations based on good-quality evidence should translate into growing confidence in doctors prescribing HRT and an increased certainty in women. However, the authors conclude that improvements are still needed in web literacy, to ensure users critically evaluate the information obtained from the web [1].

Comentario

Jen Sassarini


Obstetrics and Gynaecology, School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK



    References

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    http://www.ncbi.nlm.nih.gov/pubmed/25966991

  2. Roth JA, Etzioni R, Waters TM, et al. Economic return from the Women's Health Initiative estrogen plus progestin clinical trial: a modeling study. Ann Intern Med 2014;160:594-602


    http://www.ncbi.nlm.nih.gov/pubmed/24798522

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    http://www.ncbi.nlm.nih.gov/pubmed/17174045

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    http://www.ncbi.nlm.nih.gov/pubmed/22612616

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    http://www.ncbi.nlm.nih.gov/pubmed/26563259

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    http://www.ncbi.nlm.nih.gov/pubmed/16670414

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    http://www.ncbi.nlm.nih.gov/pubmed/21631851