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Reactions: article advocates empowerment model for managing menopause

The menopause should be tackled not just by treating specific symptoms, but more broadly, argue a group of researchers in an article published in The Lancet, one of a series on the subject. A medicalised approach can disempower women and lead to overtreatment, the authors warn. "Instead of focusing on menopause as an endocrine deficiency, we propose an empowerment model", they say. This model would incorporate the influence of psychological, social, and contextual factors that can be modified, and would also value the patient as the expert on her own condition.

05/03/2024 - 20:00 CET
 
Expert reactions

Nicolás Mendoza - menopausia EN

Nicolás Mendoza Ladrón de Guevara

Professor of Obstetrics and Gynaecology at the University of Granada, president of the Spanish Foundation for the Study of the Menopause (FEEM) and member of the Board of the European Menopause & Andropause Society (EMAS) 

Science Media Centre Spain

These articles are written in a high-impact journal by opinion leaders and make many menopause-related issues visible, most of them with a positive outlook. To sum it up in one paragraph: that menopause is a transitory state in women's lives that begins with ageing and is mostly accompanied by mild symptoms that do not need to be treated. However, a percentage of women undergo this transition with severe, persistent symptoms and its long-term consequences can lead to some medical disorders (cardiovascular diseases, osteoporosis, etc.). Another smaller percentage of women will have 'early' menopause as defined by its authors (before the age of 45) and in these cases they should be given medical attention. When it occurs before the age of 40 (premature ovarian failure or early menopause) it is considered an endocrine disease requiring hormonal treatment. 

Although they are articles written by opinion leaders, they are narrative reviews, a model for scientific publications with limitations that include individual opinions. Those of us who are also opinion leaders (I myself am the international representative of Spanish menopause specialists) say that "opinion should be separated from medical decisions". Thus, articles reflecting medical recommendations should be 'Clinical Practice Guidelines' based on systematic reviews. 

Like many scientific publications fraught with publication bias, they are written by Anglo-Saxon [authors] (USA, UK, Australia). In the Anglo-Saxon world of extreme liberalism, menopause is an impairment of job performance: this is further stigmatising women.  

The link between hormone therapies and breast cancer is, to say the least, contradictory. If the link between hormone treatments used in the Anglo-Saxon world and the risk of cancer is accepted, it is clinically insignificant and comes from patients who have been given them without indication, apart from being obese and above 60 years of age on average. Using other types of hormone therapy, in women under 60 without obesity and when indicated, no such relationship has been observed in European countries.

The author has not responded to our request to declare conflicts of interest
EN

Gino Pecoraro - menopausia EN

Gino Pecoraro

Practicing obstetrician and gynaecologist, associate professor of Obstetrics and Gynaecology at the University of Queensland (Australia) and president of the National Association of Specialist Obstetricians and Gynaecologists (NASOG)

The Australian Science Media Center

Every woman on the planet will eventually go through menopause. For some this is a relatively benign normal transition and routine part of healthy ageing but for others, debilitating symptoms can adversely affect daily living and functioning.

While it is laudable that menopause and its many presentations is finally being spoken about more openly in both the medical literature and the general population, we must be careful not to undo any good that has already been done and throw out the baby with the bathwater.

No doctor treating a woman suffering from menopausal symptoms would deny the role of empowerment and nonpharmacological treatments to help sufferers better deal with this transition. However, there remains a place for symptom control with hormonal and nonhormonal medical therapies. We must not forget that HRT [hormone replacement therapy] can have other incidental beneficial effects such as a 50% reduction in osteoporotic fracture.

Rather than trying to pitch one model of treatment over another, wouldn’t it be great if women and their doctors were aware of all treatment options and individualise treatment to the particular needs of each woman seeking their help?

Declares having given presentations for a wide range of pharmaceutical companies that make HRT products and has run workshops and lectures for GPs that have been organised and funded by multiple pharmaceutical companies.

EN

Susan Davis - menopausia EN

Susan Davis

NHMRC Investigator and Professor and Director of the Women's Health Research Program at Monash University (Australia)

Rodney Baber

Professor of Obstetrics and Gynaecology at the University of Sydney (Australia)

The Australian Science Media Center

Four papers published pertaining to menopause in The Lancet are not about new research findings but offer opinions as to how menopause might be viewed and how the experience of menopause might be optimised. 

It is disappointing that the lead article states that 'the principles of health empowerment have not been applied to menopause' when empowerment of women to best navigate their menopause, through the provision of credible health information to support informed and shared decision-making, has been the focus of national and international organisations (such as the Australasian and International Menopause Societies and Jean Hailes for Women’s Health) for many years. 

The papers raise the important concern of potential misattribution of an array of psychological symptoms to menopause. While this is also not a new concept, it is consistent with other recently published reviews and highlighting this concern reinforces the message to women and clinicians not to blame every symptom on menopause.  

The authors stress that most women will not experience debilitating menopausal symptoms. Nevertheless, they acknowledge that 60-80% of women will have menopausal flushes and sweats that can last, on average, about 7 years, and that for 1 in 3 women these can be quite severe. 

The authors caution against 'over-medicalisation' of the menopause but the messaging regarding [hormone] therapy is mixed, and potentially confusing. For example, it is stated that 'The North American Menopause Society recommends specific MHT [menopausal hormone therapy], gabapentin and oxybutynin which have mild to moderate efficacy and reduce hot flushes by 1-2 per day with no significant improvement in menopause-related quality of life'.  But, further on it is stated that MHT is effective (reduces flushes by 2-4/day) and improves health-related quality of life. Of concern is the promotion of gabapentin and oxybutynin, neither of which are approved in any country for the treatment of menopausal flushes/sweats (vasomotor symptoms) and data for oxybutynin is notably scant.  In contrast fezolinetant, which has been approved in the UK, EU, Australia and the US specifically for vasomotor symptoms, has been downplayed to being only modestly effective despite robust evidence which is lacking for these other nonhormonal therapies.

The importance of bone loss at menopause is also recognised together with the effectiveness of MHT for fracture prevention, but other long-term effects of menopause on health are called to question. This conflicts with other highly regarded expert opinions [see here and here] and this in turn demonstrates that this Lancet series needs to be seen as only one interpretation of the published research. 

The authors seem determined to minimise the important role of MHT in helping many women as they reach menopause. They ignore other published systematic reviews which all agree that MHT is the most effective treatment for vasomotor symptoms, is as effective as other bone-specific therapies (antiresorptive agents) in reducing postmenopausal osteoporosis and associated fractures and, unlike some antiresorptives, is not associated with an increased risk of fracture upon stopping treatment.

Current guidance from international and national menopause societies, including Australia and New Zealand all speak to empowerment of every woman at this pivotal stage of her life. They also stress the importance of an evidence-based approach and, importantly, offering each woman the care, support and, where required, treatment she seeks to help her on her journey.

Nonetheless, in general these papers align with, and support the latest internationally and nationally endorsed best practice guidance for menopause published in 2023, Practitioner Toolkit for Managing Menopause, with open online access for women and clinicians to facilitate health empowerment, as recommended by these papers.

Davis and Baber are both past Presidents of the International Menopause Society and Australasian Menopause Society. Davis is an NHMRC Leadership 3 Investigator. She has prepared and delivered educational presentations for Besins Healthcare, Abbott, Mayne Pharma, has been on Advisory Boards for Theramex, Astellas, Abbott Laboratories, Mayne Pharma and Gedeon Richter and has received institutional grant funding for Que Oncology and Ovoca Bio research. Baber has prepared and delivered educational presentations for Besins Healthcare, Abbott, Viatris, and Pfizer Australia and has served on medical advisory boards for Theramex, Mayne Pharma, Astellas and Besins Healthcare.
 

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An empowerment model for managing menopause
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Martha Hickey et al.

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