Ep 52 – Menopause and hormone replacement therapy (part 1)

Menopause and hormone replacement therapy (HRT) can be a source of anxiety for both patients and clinicians. Menopause is frequently in the media and is at the forefront of many consultations. It’s on our minds and on our patients’ too. In the first in a series of episodes on menopause, Dr James Waldron explores its background, its coverage in the media, the changing attitudes towards it, the impact of menopause on patients and the true risks of HRT. Future episodes in the coming weeks will explore prescribing and other treatments.

Key references discussed in the episode:

1. NICE CKS. When should I suspect a diagnosis of menopause or perimenopause? March 2022.
2. Menopause: diagnosis and management. NG23. 5 December 2019.
3. Haskey J. Is the menopause affecting your business? The Menopause Charity.
4. Cagnacci A, Venier M. Medicina (Kaunas). 2019;55(9):602. doi: 10.3390/medicina55090602.
5. Rossouw JE, et al; Writing Group for the Women's Health Initiative Investigators. JAMA. 2002;288(3):321-33. doi: 10.1001/jama.288.3.321.
6. Collaborative Group on Hormonal Factors in Breast Cancer. Lancet. 2019;394(10204):1159-1168. doi: 10.1016/S0140-6736(19)31709-X.
7. Thrombotic risk of contraceptive transdermal patches and the contraceptive vaginal ring. Prescrire Int. 2013;22(143):266, 268-9.

Useful resources

• Understanding the risks of breast cancer infographic
• Menopause Matters (for patients)
• British Menopause Society (for healthcare professionals)

Key take-home points:

1. Don’t underestimate the impact of menopause on the patient. It can cause issues physically, emotionally, psychologically and sexually.
2. Menopause can be underreported and under diagnosed but is at the forefront of patients’ mind due to increased media coverage.
3. Carefully consider the way you counsel patients about HRT because patients have significant worries about side effects and taking medication.
4. Use a thorough history and a patient’s symptoms to guide treatment. Practical measures can be helpful along with cognitive–behavioural therapy, but HRT can be an effective and relatively safe option for many patients.
5. Our understanding of the risks of HRT has changed but, although the risks are not as high as we once thought, clinical practice in primary care is slow to change.
6. HRT can have a positive effect on cardiovascular risk when started earlier, and it has demonstrated an overall improvement in all-cause mortality.
7. Transdermal preparations of HRT do not have an increased risk of venous thromboembolism (VTE), but when taken orally, the VTE risk is dose-dependent.