Written by Dr Karen Morton, consultant obstetrician and gynaecologist and Founder of Dr Morton’s – the medical helpline.
Congratulations to the organisers of the British Menopause Society’s 26th Annual Conference at the Royal College of Physicians on Thursday and Friday 19 and 20 May 2016. Both content and organisation were excellent, and I am sure every one of the delegates: GPs, gynaecologists and Specialist nurses, will all have left London inspired to give their patients the most up to date advice and to become evangelists for optimising the health of women in their middle years and beyond.
So What’s New About Menopause in 2016? What were the take-home messages?
The title of the conference was ‘NICE Menopause Guideline: from publication into practice’, so clearly time was spent looking at the key messages from the 29 page NICE recommendation document which was published in the Autumn of 2015. But there were also several lectures on the periphery of what NICE looked at which gave out clear messages for change or enhancement of practice.
For me the striking messages were:
- Women should talk about their problems and get help. Awareness of women’s needs at this time in their lives should have prominence in the workplace. More about this later.
- Good diet and lifestyle with regular exercise, moderate alcohol intake and not smoking are more important than anything else. OF course!
- Oestrogen-only HRT (only suitable for women who have had their uterus removed) causes no significant increase in breast cancer. If you have a uterus it must be protected with progestogen and after several years of taking it, this combination probably causes a very small increased risk of breast cancer, but this risk reverts back to where it was when you stop it.
- HRT does not increase the risk of heart attack as long as it is started under the age of 60. More about that later as well!
- Cognitive behavioural therapy can be helpful with symptom control.
- HRT should be taken through the skin if you have an increased risk of DVT.
- It’s fine to continue HRT for as long as the woman wishes.
- You can either stop HRT gradually or immediately.
- Vaginal oestrogen may be needed in addition to through the blood stream. This doesn’t seem very logical to me as women who have a normal circulating oestrogen level with their HRT are surely the same as a premenopausal woman?
- Measuring the follicular stimulating hormone level (FSH) has limited or no value over the age of 45 as it can fluctuate so much. Treat the symptoms rather than the blood test.
So now to the fascinating science which was presented by the two Professors from the United States. Both gave brilliant lectures.
Prof Pauline Maki from the University of Illinois showed that the troublesome memory loss which women so commonly report during the perimenopause is real, although fortunately, some years after menopause there is some recovery. Additionally she showed that women with moderate to severe hot flushes had worse verbal memory loss than women who did not have flushes, or women in whom flushes were controlled with HRT, or wait for it…… controlled by stellate ganglion blockade which is an injection used for pain management and blocks nerve pathways; in other words nothing to do with the hormones per se. Very interesting!
Prof Rogerio Lobo from the Columbia University College of Physicians and Surgeons presented evidence to show that the timing of starting HRT is crucial not only to get most benefit but to avoid the treatment have some early harmful effects on cardiovascular disease. He elegantly demonstrated that if oestrogen is started after harmful atherosclerotic plaque has already been deposited, the action of certain oestrogen induced chemicals on the plaque can cause it to fragment and break away, causing arterial blockage and cardiac or other events. When oestrogen is started early it positively reduces the development of atherosclerosis. His conclusion was that starting HRT earlier, as oestrogen levels decline, would produce greatest benefit.
What else did I learn? Well often you go to conferences and are reassured that things you have done for a long time were correct all along. Some aspects of the BMS conference were like that, but actually there were more take-home messages than usual. Prof Amanda Griffiths from Nottingham University presented data showing how important and under addressed menopausal problems were in the workplace. She high-lighted how performance and productivity could be enhanced by a proactive approach for menopausal problems by employers and line managers. I learned that all postmenopausal women should be taking a Vitamin D supplement and were very unlikely to need calcium supplements. Of course HRT remains the first line treatment for osteoporosis and for prevention too. I also learned that TSH levels fluctuate a lot and that a TSH of between 4.5 and 10 should lead to measuring anti thyroid antibodies and only if they are positive would you start treatment.
Finally I appreciated how difficult it is to get information about the menopausal problems in any women other than white middle class ones. A very well intentioned survey was presented using surveymonkey and the respondents were 93% white; clearly not representative of the ethnic mix in Britain and raising the question as to whether surveys of this nature really produce useful data.
All in all a great conference and some interesting infographics!