New menopause toolkit includes bone treatment

6 minute read

The updated guideline, the first to include bone health advice, comes amid calls for a national inquiry into menopause and perimenopause.

Low-risk postmenopausal women don’t need MHT purely to prevent fracture, but the drugs should be considered in all patients with osteopenia under age 65, according to new Australian and international guidelines.

This update from the 2014 guidelines provides clearer advice about preventing bone loss and fracture, according to Melbourne endocrinologist and first author Professor Susan Davis.

“To our knowledge this is the only document that provides guidance for using hormone therapy to prevent fracture,” said the Monash University Women’s Health Research Program head.

“Other recommendations have been vague such as ‘can be used to prevent bone loss/fracture’ or ‘use to treat osteopenia’.”     

It comes as Greens leader in the Senate and spokesperson on women Senator Larissa Waters moves to put menopause and perimenopause on the national agenda by calling for a Senate inquiry.

A spokesperson for Senator Waters confirmed she was planning to move the motion in parliament on Monday.

According to the new guidelines, a peripheral or femoral neck T-score of -1.8 or less “offers a pragmatic, conservative, cut-off point after which fracture risk increases in postmenopausal women aged <65 years”.

“When applying this cut-off, both the individual’s BMI and time since menopause need to be taken into consideration,” it says. “MHT has been shown to prevent bone loss and fragility fractures in all postmenopausal women irrespective of BMD and other risk factors.”

MHT will likely reduce the risk of fractures in asymptomatic postmenopausal women aged under 65 with a T-score of -1.8 or less, and the benefit will outweigh any potential risk in many women, it said.

Most women aged 45 and over do not need hormonal testing for menopause to be diagnosed, according to the new guidelines.

But hormone measurement “may be useful” for amenorrhoeic women with fluctuating or subtle symptoms such as mood changes and no or few vasomotor symptoms, it says.

“A single observation of normal FSH and oestradiol does not exclude perimenopause as hormone levels fluctuate at this time.”

Around 75% of postmenopausal women over 55 have vasomotor symptoms, it says, and women with moderate to severe vasomotor symptoms are up to three times more likely to have moderate to severe depressive symptoms than other women.

MHT is the most effective treatment to alleviate vasomotor symptoms, and it suggests oestrogen therapy or tibolone in most women.

Hormone measurements are needed for a diagnosis of premature ovarian insufficiency, in which follicle stimulating hormone is elevated and oestradiol needs to be low on at least two occasions at least four to six weeks apart.

“Other investigations are usually indicated once POI is diagnosed,” the toolkit says.

All women should be reviewed at menopause for their cardiovascular disease risk (blood pressure and lipids), diabetes (fasting blood glucose), urogenital health (considering hormonal and non-hormonal therapy) and cancer screening (breast check, mammogram and cervical cancer screening).

Menopausal hormone therapy is indicated after perimenopause to alleviate symptoms of menopause such as vasomotor symptoms, menopause-associated sleep disturbance or mood change, and vaginal dryness, it says.

And some non-hormonal therapies have evidence to support their use to alleviate vasomotor symptoms.

“The selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are effective in some, but not all, women with VMS. Paroxetine, 7.5mg/day, has regulatory approval for VMS in the USA.”

The toolkit says fezolinetant – a neurokinin 3B receptor antagonist that acts in the brain – reduces vasomotor symptoms and may improve sleep quality. But the drug hasn’t been approved for the treatment of vasomotor symptoms in Australia.

Androgen therapy may be helpful in some cases, according to the toolkit.

“Transdermal testosterone therapy for postmenopausal women with sexual desire dysfunction, given in a female-appropriate dose, may improve sexual desire, arousal, orgasm and pleasure.”

But otherwise, there’s no other evidence-based indication for testosterone therapy for women, and oral DHEA is not effective for the treatment of postmenopausal sexual dysfunction.

“In addition, systemic DHEA has not been found to be clinically beneficial for the treatment or prevention of any other symptoms or conditions,” it adds.

The toolkit says weight reduction may help reduce vasomotor symptoms in overweight women. Exercise, yoga and relaxation methods haven’t been found to be effective for vasomotor symptoms, but they may improve sleep and general well-being, it says.

The move for an inquiry already has support from Australian doctors who want to see more funding to improve access to appropriate healthcare and medicines for menopausal women, including MHT.

They also want to see menopause education improved both in medical schools and in the community.

Dr Ceri Cashell, a GP in Avalon on Sydney’s northern beaches with a special interest in women’s health, said an inquiry would be an opportunity to make menopause a national priority and “grow awareness with key decision makers who control the funding and policy”.

“Every person with a uterus who lives to midlife experiences menopause,” she wrote in a LinkedIn post. “Women’s hormonal health affects every aspect of the fabric of our society. We need much better medical education for all health professionals, improved public awareness of the whole range of symptoms and affordable gold-standard drug treatment that is accessible to all women.

“This will serve to improve the world as we know it, from individual health to family stability to improved workplace productivity and keeping women in work at the peak of their careers.”

Dr Cashell told TMR there was an urgent need for a national discussion about MHT for women with menopausal and perimenopausal symptoms beyond hot flushes and night sweats.

“We know at the minute and certainly my experience is that most women do not recognise symptoms other than the typical flushes and flashes and sweats,” she said.

“They do not think of their insomnia, anxiety, cognitive dysfunction to be menopause. And so we need people to be aware of this.”

Access to subsidised gold-standard medication like MHT also needed to be a priority for the inquiry, as well as securing supply chains in Australia to prevent national shortages.

Dr Cashell urged doctors around Australia to join the groundswell of support for the proposed inquiry.

“We need as many people as possible calling, writing and posting to social media to let senators know this matters to so many of us,” she said.

Climacteric 2023, online 30 October

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