18 April 2016: 

Despite the availability of effective hormonal and non-hormonal treatments for menopausal symptoms, few women with these symptoms are evaluated or treated  

Whoever can download from The New England Journal of Medicine and read the paper by Manson and Kunitz entitled 'Menopause management: getting clinical care back on track', or from the relevant commentary in Medscape must do so at their earliest convenience [1,2]. As a reminder, the authors were among the WHI study investigators, and Manson was also a Steering Committee member. Needless to detail again the consequences of the misinterpretation of the initial WHI study results, which reduced the use of postmenopausal hormone therapy (HT) by 80% or even more, just because of misunderstanding of its safety profile in recently menopausal women. Many later studies discussed the adverse outcomes of banning HT, mainly related to quality of life issues and bone health. The best would be just to bring some quotes from the article (in italics).

Despite the availability of effective hormonal and non-hormonal treatments for menopausal symptoms, few women with these symptoms are evaluated or treated. Leading medical societies devoted to the care of menopausal women agree that systemic hormone therapy is the most effective treatment currently available for these symptoms and should be recommended for women with moderate-to-severe vasomotor symptoms, in the absence of contraindications. Such criteria apply to approximately 20% of women in early menopause, most of whom remain untreated despite having symptoms that adversely affect their daily activities, sleep, and quality of life. Women's decisions regarding such therapy are now surrounded by anxiety and confusion. The WHI trial was designed to address the risks and benefits of long-term use of hormone therapy for the prevention of chronic disease in postmenopausal women who were on average 63 years of age at initiation of therapy. But the results are now being used inappropriately in making decisions about treatment for women in their 40s and 50s who have distressing vasomotor symptoms. The new generation of medical graduates and primary-care providers often lacks training and core competencies in management of menopausal symptoms and prescribing of hormonal treatments. Most primary-care residency programs in the United States don't provide adequate education in women's health in general or in menopause management in particular. Reluctance to treat menopausal symptoms has derailed and fragmented the clinical care of midlife women, creating a large and unnecessary burden of suffering.

This is actually an important message, created by lead WHI investigators, and published in the most prestigious medical journal. The WHI saga should teach us that extrapolation of clinical data, which were collected with a specific aim and protocol, to other clinical scenarios may be wrong and may even cause harm to populations that could benefit from the use of certain therapies but avoid it as a result of disinformation and lack of sufficient knowledge.

Another recent study brings real-life data from five European countries [3]. Of 3890 peri- to postmenopausal women screened, 67% experienced symptoms and 54% sought either medical input or some treatment concerning their symptoms. Roughly 75% of women who sought relief consulted a physician. Approximately 79% visiting a physician received prescription therapy. Of the women who received non-hormone therapy instead of HT, the reasons were: patients refused HT (20–44% in the various countries), physicians did not discuss HT (32–46%), or advised against HT (24–43%). So this is the problem in a nutshell: women do not seek treatment because of concerns, physicians do not prescribe HT because of unjustified fears or lack of knowledge. The recent IMS recommendations on midlife health and menopause hormone therapy highlight the relevant issues and may be used as an updated source of educational information [4].

Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

References

1. Manson JE, Kaunitz A. Menopause management: getting clinical care back on track. N Engl J Med 2016;374:803-6
http://www.ncbi.nlm.nih.gov/pubmed/26962899

Menopause Management — Getting Clinical Care Back on Track291.7 KB

2. A short lecture by Manson, and accompanying commentary in Medscape website on the above article.
http://www.medscape.com/viewarticle/859512?nlid=101267_430&src=WNL_mdplsfeat_160308_mscpedit_fmed&ua

3. Constantine GD, Graham S, Clerinx C, et al. Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries. Post Reprod Health 2016 Feb 18. Epub ahead of print
http://www.ncbi.nlm.nih.gov/pubmed/26895640

4. Baber RJ, Panay N, Fenton A, and the IMS Writing Group. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric 2016;19:109-50
http://www.ncbi.nlm.nih.gov/pubmed/26872610