To take or not to take medication for menopausal symptoms?  There is a pill war going on around menopause

To take or not to take medication for menopausal symptoms? There is a pill war going on around menopause

Doctors medicalize the menopause too much and that does not make this phase of life any easier for women. Allowing women to take control of their complaints often helps them through the menopause better than medication. That is, in short, the gist of a recent article The Lancet. The authors write this while the demand for hormone therapy is increasing and a new non-hormonal drug is being welcomed with open arms.

A different approach to menopause is needed, write the seven authors from different disciplines. Australian gynecologist Martha Hickey, the first author, has been campaigning for the normalization of menopause for years. Together with the British professor of psychology Myra Hunter, the last author, she points out the importance of ’empowerment’. This word, which is difficult to translate, means that women gain sufficient knowledge and self-confidence to tackle their complaints in a well-informed manner and decide on treatment with the doctor.

In the two years after their last menstrual period, 60 to 80 percent of women experience hot flashes. It usually starts earlier and lasts about four to seven years. On top of those hot flashes and night sweats, there is often poor sleep, muscle and joint pain, a dry vagina, urine loss, fragile bones and sometimes also memory problems, mood swings and even depression.

Pretty taxing

There is no doubt that the drop in estrogen can cause hot flashes, but many complaints attributed to menopause have other causes – just think of the combination of work and informal care for aging parents.

Although this stage of life is quite stressful for many women, the idea that menopause is “a period of decline and decline” must be challenged, the authors write. Over the course of the last century, menopause was increasingly seen as a disease shortage to hormones, the authors write, and not as a normal change in hormone balance. Although many women appeared to benefit from hormone replacement therapy, the pharmaceutical industry in particular benefited from the medicines that could potentially serve half the world’s population.

The use of hormone therapy collapsed in 2002 after a study on it was stopped because too many women appeared to be developing breast cancer. And although later studies nuanced the results, use never fully recovered. Yet demand has been growing again in recent years, possibly also because there is a lot of media attention for menopause – something that the authors do not necessarily see as something positive, because the emphasis is often on the burden.

Acceptable risk

The percentage of women using hormone therapy in the Netherlands has almost doubled in the past ten years, according to figures from the Foundation for Pharmaceutical Key Figures. NRC collected. In 2013, 3.5 percent of women in the menopause phase used hormone preparations, last year that was 6.5 percent – much lower than the 15 percent in the United Kingdom. An explanation for the increase in the Netherlands may be that the general practitioner guideline has offered more scope to prescribe it since 2022, because the consensus is now that the minimal risk of breast cancer is acceptable if the quality of life improves.

The authors do not dispute that hormone therapy is effective. But especially against annoying hot flashes and night sweats. And it doesn’t work equally well for everyone. In addition, hormone therapy can initially cause more blood loss during the period and worsen urine loss. And they haven’t finished talking about the breast cancer risk either. They cite a meta-analysis from 2019 The Lancet with an estimate that one additional woman in 50 will develop breast cancer after five years of combination therapy (estrogen and progestin).

The authors do not argue against hormone therapy for women with serious complaints. In particular, they emphasize that empowerment and normalization of menopause is necessary to enable women to choose the best treatment. Advice about healthy habits that can reduce complaints, such as healthy food, sleep and not too much stress. Offering behavioral therapy can also help women. And women need to be reassured, because fear of hot flashes can worsen the complaints. “Women feel strengthened when they know how to deal with their complaints. Self-confidence and a sense of control improve the way women experience menopause,” they write.

It is precisely the stigmas, first on menstruation, and then on menopause and aging, that bring women down and make menopause an unpleasant period, they write, referring to the feminist book Period, about menstruation. “In cultures with more respect for old age, such as indigenous communities in Australia, menopause is less problematic.” And medical research focuses mainly on new medicines, while most women, the authors claim, do not want any medicines at all.

The Lancet published the article about the ’empowerment model’ in a series of four articles about menopause. Together they also show something about the wave movement and directions in thinking about menopause, in which hormone therapy is alternately seen as salvation and danger.

Women must make informed choices for themselvesDorenda van Dijken gynaecologist

Dorenda van Dijken, gynecologist at the OLVG hospital in Amsterdam, has also specialized in menopausal complaints for almost thirty years and until recently chaired the Dutch Menopause Society, also sees this trend. She does have something to ‘grumble’ about the empowerment article, which mainly mentions the downside of hormone therapy. “They mix up different hormone therapies. And the International Menopause Society was very critical of the 2019 Lancet study on breast cancer risk.” The study involved hormone compounds that are no longer prescribed. The risk of breast cancer is significantly smaller for women who receive the current bioidentical hormones and doses that many guidelines, including the Dutch ones, prescribe.

80 percent of women have menopausal symptoms, of whom only a small proportion receive hormone therapy in the Netherlands, says Van Dijken. This is difficult to qualify as overmedicalization. “I think it’s a bit of a shame that women are once again hearing that you have to embrace menopause, just now that there is finally recognition that their complaints can be very hindering.” The Lancet authors talk about “reassuring”, doctors must explain clearly that complaints are normal and will disappear on their own. “But is that ’empowerment’? I wonder. I think that women should make well-informed choices for themselves.”

Van Dijken does not think the warning against overmedicalization is bad in itself, now that many “self-appointed hormone specialists without any medical background” use and advise up to eight times the permitted dose against the guidelines, and some doctors write prescriptions for this. “But I often see wrecks, women with serious complaints who see their quality of life improve significantly with hormone therapy.” Moreover, says Van Dijken, “we always start with nutrition and lifestyle. We really don’t immediately prescribe hormone therapy at the first hot flash.”

Much of what is advocated in the Lancet paper is just starting to get off the ground in the Netherlands. In the coming years, a new MenoPause Consortium, led by Peter Bisschop, professor of endocrinology at the Amsterdam UMC, will conduct research into sleep, physical and mental health and work with a subsidy of 9.4 million euros. Precisely to see how, for example, behavioral therapy and lifestyle adjustments can better help women through the menopause.

As beautiful as those hormones are, be carefulMonique Brood-van Zanten doctor

This consortium, like the Lancet paper, emphasizes how important the role of employers is. One in three working women notices that menopausal symptoms have a negative impact on their productivity, for example because they sleep worse. The research is accompanied by a campaign to make the transition more open to discussion in society. A trial into the effect of hormone therapy has already started, to discover what duration and dose help prevent osteoporosis in women at increased risk. The researchers explicitly write on their site that the bioidentical hormone patches that participants receive pose no risk of breast cancer, thrombosis or weight gain.

Most women do not want medication, Hickey and her colleagues write firmly The Lancet. Yet many doctors and women were eagerly awaiting a new, non-hormonal drug, which has been on the market in the Netherlands since April 1. This concerns Veoza, the active ingredient of which is fezolinetant, which acts on signaling substances that regulate the temperature control center of the brain. Studies to date show that it is not as effective as hormone therapy in all cases, but it does work better against hot flashes than other non-hormonal agents.

“We were really waiting for it,” says Monique Brood-van Zanten, doctor and co-author of the menopause guideline. At the Antoni van Leeuwenhoek and Amsterdam UMC (gynecology) she treats women after cancer, who are not always allowed to use hormone therapy against hot flashes and night sweats. Until recently, bread had little to offer them other than medicines that were actually developed for something else, such as gabapentin (epilepsy and nerve pain), clonidine (high blood pressure) and certain antidepressants.

Herbal remedies

Brood also sees that there are many “well-intentioned” herbal remedies on the market. “But we don’t recommend that.” An exception is a certain black cohosh extract – not the jars that are among the supplements at the drugstore, but the registered herbal medicine, which is also included in the treatment guidelines in Germany. “It has a fixed dosage per tablet. But there are restrictions. You should not use it for more than six months without medical supervision.” And how well does it work? “Better than placebo. But it has also been shown that even if you tell women to get a placebo, they have fewer hot flashes.”

Fezolinetant is currently the only non-hormonal drug that even comes close to hormone therapy in terms of effectiveness. As long as it is not reimbursed, it costs women about 55 euros per month.

What Brood would most like to see is that women receive more guidance in this phase of their lives. “Why during pregnancy and not during menopause? Women think they are well informed, but what they see online is often misleading. Then they take more estradiol than prescribed and come to us with bleeding. As beautiful as those hormones are, be careful, it is not good for everyone and the risks of breast cancer are not great, but the consequences can be serious.”