Menopause Guidelines and Why Britain Deserves a Thumbs Up

Guidelines for practicing medicine come from various organizations, which usually are professional societies comprised of experts in a particular field.  The members of the group review the studies on a given treatment or test and come up with a list of recommendations.  Only the best quality of evidence is considered in making their determinations.  After carefully reviewing all the data, guidelines are written and made available to healthcare providers who use them to guide patient care decisions.

For instance, doctors look to guidelines to choose the best treatment for bladder infections.  The guideline makers evaluate a number of antibiotics and consider such attributes as the efficacy of the antibiotic in treating the most common bugs that cause infections, the side effects of a given antibiotic, and how likely the infecting organism is to become resistant to any given drug.  Based on these factors, it is determined which antibiotic should be the first choice, and alternatives are suggested if the patient has an allergy.  Other issues that the guidelines spell out are the number of days the infection should be treated and what to do if the infection comes back.

Over time as medical knowledge is gained from new studies, guidelines change to reflect the latest best practices.

Different organizations may have different guidelines for a given medical issue.  For instance the American Cancer Association’s recommendation for how often to get a screening mammogram differs slightly from the American College of Obstetricians and Gynecologist’s, and both of these differ from a governmental agency called the United States Preventative Services Task Force (USPSTF).  Some recommend a mammogram every year; others every two years.  Some recommend staring at age 40; others age 45.  For the most part, however, the guidelines from different groups don’t tend to differ dramatically.

What is behind the Guidelines for Menopause in the US?

Guidelines from different countries may differ.  Although we in America tend to view ourselves as quite sophisticated when it comes to medical care, there is one area where I think we are lagging behind other countries.  And this is when it comes to menopause.  In a previous post, I outlined the US guidelines and lamented that they are based heavily on a study performed twenty years ago – the Women’s Health Initiative Study (WHI).  This study concluded that hormone replacement therapy (HRT) causes more risks than benefits.  Because of this, guidelines were developed that essentially discourage hormone treatment.  In a nutshell, the guidelines recommend estrogen only for women having severe hot flashes and to only use the lowest doses of hormones for the shortest periods of time.  Doctors are advised to not prescribe HRT to prevent long-term complications.

These guidelines have persisted for the last 18 years and millions of women in the US have not been placed on HRT when they go through menopause.

The problem with basing our guidelines on the WHI is that the women in this study were not representative of the typical woman entering menopause.  Most of them were over age 60 and HRT was initiated a number of years after they went through menopause.  So while the conclusions of the WHI should apply only to this category of women, its results have been generalized to apply to all women.  This is inappropriate because there is compelling evidence attesting to the safety of estrogen for women who are just entering menopause and that beginning HRT at this point leads to more benefits than risks.  Although the North American Menopause Society’s most recent position statement reflects this, this message just isn’t getting acknowledged in most of the current menopause guidelines in the US.

Let’s talk about Britain

In October 2020, the British Menopause Society published an updated summary of recommendations for menopause treatment.  A nice review of these guidelines can be found at their website. These recommendations are supported by the National Institute for Health and Care Excellence (NICE), which provides national guidance for citizens in the UK.  I was very impressed to see that the safety and benefits of estrogen therapy are reflected in these guidelines.

Highlights of the document include:

•  The decision whether to take HRT, the dose of HRT used and the duration of its use should be made on an individualized basis after discussing the benefits and risks with each patient
•  Arbitrary limits should not be placed on the duration of usage of HRT
•  Cochrane analysis suggests that HRT started before the age of 60 or within 10 years of the menopause is associated with a reduction in atherosclerosis progression, coronary heart disease and death from cardiovascular causes as well as all-cause mortality
•  Women should be reassured that HRT is unlikely to increase the risk of dementia or to have a detrimental effect on cognitive function in women initiating HRT before the age of 60
•  Current evidence suggests that estrogen-alone HRT is associated with little or no change in the risk of breast cancer while combined HRT can be associated with an increased risk which appears duration-dependent and may vary with the type of progestogen used.  However, this risk is low in both medical and statistical terms, particularly compared to other modifiable risk factors such as obesity and alcohol intake, and this should be taken in the context of the overall benefits obtained from using HRT
•  HRT should be considered the first-line therapeutic intervention for the prevention and treatment of osteoporosis in women with premature ovarian insufficiency (POI) and menopausal women below 60 years of age, particularly those with menopausal symptoms

In reviewing these documents, it is clear to me that the UK is sending a distinctly different message to menopausal women than the one being promulgated in the US.  Hopefully, America will follow Britain’s lead in putting the risk and benefits of HRT in a more realistic perspective and stop discouraging women from taking estrogen.

I welcome your comments or questions!