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This is us with our jaws on the table. Really this is earthshaking.
International Menopause Society has issued revised "treatment" recommendations for menopause.
In the post-WHI terror years, this major medical practice group promulgated some of the most restrictive and negative of the major sets of guidelines, providing frightened physicians the backup they needed to withhold HRT from many desperately miserable women.
But with additional analysis of WHI data plus results accumulating from other studies, a more rational outlook is prevailing that goes back to a sensible, individualized approach. We really urge you to download and read this whole document, but the guiding principles section, which we are quoting, is brilliant in terms of summarizing much of what we work with and believe here:
Hormone therapy should be part of an overall strategy including lifestyle recommendations regarding diet, exercise, smoking and alcohol for maintaining the health of postmenopausal women. HT must be individualized and tailored according to symptoms and the need for prevention, as well as personal and family history, results of relevant investigations, the woman's preferences and expectations. The risks and benefits of HT differ for women around the time of menopause compared to those for older women.
HT includes a wide range of hormonal products and routes of administration, with potentially different risks and benefits. Thus, the term `class effect' is confusing and inappropriate.
Women experiencing a spontaneous or iatrogenic menopause before the age of 45 years and particularly before 40 are at higher risk for cardiovascular disease and osteoporosis. They will benefit from hormone replacement, which should be given at least until the normal age of menopause.
Counseling should convey the benefits and risks of HT in simple terms, e.g. absolute numbers rather than as percentage changes from baseline expressed as a relative risk. This allows a woman and her physician to make a well-informed decision about HT.
HT should not be recommended without a clear indication for its use.
Women taking HT should have at least an annual consultation to include a physical examination, update of medical history, relevant laboratory and imaging investigations and a discussion on lifestyle.
There are no reasons to place mandatory limitations on the length of treatment.
Whether or not to continue therapy should be decided at the discretion of the well-informed hormone user and her health professional, dependent upon the specific goals and an objective estimation of benefits and risks.
Dosage should be titrated to the lowest effective dose. Lower doses of HT than have been used routinely can maintain quality of life in a large proportion of users. Long-term data on lower doses regarding fracture risk and cardiovascular implications are still lacking.
In general, progestogen should be added to systemic estrogen for all women with a uterus to prevent endometrial hyperplasia and cancer. However, natural progesterone and some progestogens have specific beneficial effects that could justify their use besides the expected actions on do not require progestogen co-medication. Direct delivery of progestogen to the endometrial cavity from the vagina or by an intrauterine system is logical and may minimize systemic effects.
Androgen replacement should be reserved for women with clinical signs and symptoms of androgen insufficiency. In women with bilateral oophorectomy or adrenal failure, androgen replacement has significant beneficial effects, in particular on health-related quality of life and sexual function.
So, there you are in one fell swoop: no arbitrary end limit, individualization and lifestyle as important, need for HRT by younger women, goal-driven use, progesterone uses beyond the uterus, vaginal estrogen support, androgen use supported and defined—the whole thing. This is, to put it simply, very very exciting.
Every one of you who has been stymied in the things you've asked for can now print this out and take it to your doctor and suggest that perhaps he might find it useful to review the latest guidelines from this very conservative group. In fact, go whole-hog and take along the Endocrinologists' Society guidelines too! These two remarkable documents do more to provide us with unassailable foundations for meeting our needs than any of us would have dared hope just a few years ago.
The recommendations provide a very good discussion of risks and benefits. In particular, the discussion of breast cancer risk is very concrete and clearly points out the soft spots in many of the "scare" studies, such as the fact that the majority of the WHI participants were obese as well as over age 63—things that are independent risk factors for many of the negative effects attributed to HRTs in the initial analyses. It is also very specific about how (and by which estrogens and progestogens) breast cancer is stimulated.
For those here worried about being "late starters," the recommendations point, as we have in our discussions, to the lowered CV risk posed by transdermals and low doses.
There is acknowledgment that some drug regimens may help with hot flashes, but that additional work on risks is needed in order to compare those drugs to HRTs in terms of overall risk. This is very important for those whose doctors are frightened of HRT risks but assert that drug risks are trivial—something we have viewed with skepticism all along.
On the topic of compounded blends, the initial look is negative:
There are no medical or scientific reasons to recommend unregistered `bioidentical hormones'. The measurement of hormone levels in the saliva is not clinically useful. These `customized' hormonal preparations have not been tested in studies and their purity and risks are unknown.
But in fact this is, aside from the saliva testing disregard (which we're afraid we have to agree with for reasons posted elsewhere in some detail), this is actually a dazzlingly neutral stance considering the strong anti-compounding lobbying the pharmaceutical manufacturers are carrying out in conjunction with the medical insurance companies. Failure to condemn them holds the door open to possible future endorsement once ("if" is actually the more likely situation, considering the funding of research being primarily provided by pharmaceutical companies) more targeted research is performed. This is, again, wildly more positive than we might have expected from this group and the overtly political process that forging such a public statement involves.
The rest of the document is a set of bulleted points on specific symptoms, systems, and recommendations. These are all in really quite readable text with a minimum of medical terminology. The osteoporosis section, for example, recommends 700 IU of vitamin D daily in addition to calcium. That's an encouragingly firm figure from an authoritative and conservative source, for those looking to feel supported in moving their dose up beyond the old US FDA standard of 400 IU.
Basically, this ticks through every system and records, clearly, the findings of research and how they pertain to practice. It is very clear on the benefits of HRTs and how to minimize the risks (repeated emphasis, for example, on where transdermals differ from orals).
Oh, and we can't resist quoting this, for those of you whose doctors have insisted that you are just crazy when you complain of brain fog and memory loss:
New results from recent in vivo randomized, controlled neuroimaging experiments demonstrate that, in young females and those in midlife: *brain function is modulated by normal variation in ovarian function; *acute loss of ovarian hormones increases neuronal membrane breakdown; *acute suppression of ovarian function is associated with reduced activation of brain regions critical to memory. |
