Menopause is a natural part of ageing and should not be perceived as an illness or medical condition. However, it is crucial to recognise that the repercussions of menopause often detrimentally affect women's overall well-being and quality of life.
BESIDES HOT FLUSHES and night sweats, women may also experience mood swings, memory impairment, urogenital atrophy, decreased libido, sleep disturbances, joint pain, and muscle stiffness. The decline in oestrogen levels and other physiological changes associated with menopause significantly heighten the risk of developing cardiovascular disease, osteoporosis, diabetes, and dementia among affected women. These symptoms can vary in intensity and could persist for several years or even decades.
There is clear evidence to support that, in addition to a benefit on symptoms, hormone replacement therapy (HRT) can also play a role in quality-of-life improvement, prevention of coronary heart disease, osteoporosis and fracture risk, and reduction in mortality. No other treatments for menopausal symptoms have demonstrated a similar role. This is shown in guideline recommendations including from the National Institute for Health and Care Excellence (NICE).
A cumulative 18-year follow-up of the Women’s Health Initiative trials demonstrated that women taking HRT did not have a higher risk of all-cause, cardiovascular, or cancer mortality.
HRT is available mainly as oral or transdermal preparations, all of which contain oestrogen, either alone or combined with progestogen.
MODE OF OESTROGEN DELIVERY
A systematic review and meta-analysis of treatment effects from NICE guidelines showed that transdermal oestradiol had the highest probability of being the most effective treatment for vasomotor symptoms compared with placebo.
Studies have shown no association between VTE risk and use of transdermal oestrogens. Guidelines also recommend transdermal rather than oral HRT for menopausal women who are at increased risk of VTE, including those with a BMI >30kg/m2.
Oral HRT-containing oestrogen at either high or low doses is associated with an increased risk of ischaemic stroke, compared with non-users. However, transdermal preparations containing low doses of oestrogen are not associated with this risk.
The British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women states that HRT should be considered the first-line therapeutic intervention for the prevention and treatment of osteoporosis in women with premature ovarian insufficiency and menopausal women below 60 years of age. A 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. Cochrane data-analysis as well as the long-term follow-up data from the Women’s Health Initiative (WHI) showed no increase in cardiovascular events, cardiovascular mortality or all-cause mortality in women who initiated HRT more than 10 years after the menopause.
Vaginal oestrogen is not associated with an increased risk in breast cancer.
References available on request.