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Are We Overmedicalising Menopause? – Expert Reaction

Australian experts warn about the overmedicalisation of menopause and call for a new approach to how society views menopause and supports women as they age, in a new series of papers published today in The Lancet.

The authors say a new approach to menopause that better prepares and supports women during midlife is needed – going beyond medical treatments, to empower women using high-quality information on symptoms and treatments, empathic clinical care and workplace adjustments as required.

The SMC asked independent experts to comment.

Associate Professor Michelle Wise FRANZCOG, Department of Obstetrics and Gynaecology, FMHS, University of Auckland, comments:

“I am pleased that such a prestigious journal has chosen to focus on menopause, given it affects half the population. The quality of the writing and such an excellent summary of current research evidence makes this a must-read for all clinicians.”

Comments on the paper An empowerment model for managing menopause:

“I could not agree more with the premise that we should support women going through menopause in a holistic manner and consider all aspects of health and well- being, rather than regarding this phase of life as a disease. As a Gynaecologist in a large urban hospital, I unfortunately hear from many of my patients that they are initially dismissed by their families, friends and health practitioners when they present with menopause symptoms. In New Zealand, a good source of evidence-based information is the Australasian Menopause Society.

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“It is crucial to have information on all aspects of menopause; a decision aid takes women and their clinicians through a values- and preferences-based exercise that can be the basis for a shared decision-making model about best treatment options. A great resource to prepare for these conversations can be found at My Menoplan. Many women will not want treatment per se, but can be empowered with balanced information, empathy, validation and unbiased help with making decisions.

“For women who seek treatment, Menopausal Hormone Therapy (MHT) is the most effective treatment for hot flushes and night sweats, alongside many other symptoms that are attributed to menopause such as difficulty sleeping and decline in memory and concentration. MHT also improves overall quality of life. Not all MHT formulations are funded in New Zealand; some are partially funded (such as Kliovance) and others not at all (such as EstroGel, Vagifem, Duavive).

“The most effective non-hormonal therapy for improving hot flashes, sleep and mood is cognitive behaviour therapy, but this is usually available only in the private sector. Other non-hormonal therapies with research evidence supporting their use to improve hot flashes are clinical hypnosis, SSRI, gabapentin, and oxybutynin. The newest medication is Fezolinetant, but this is not available in New Zealand.

“What concerns me is the amount of inaccurate information found all over the internet and social media, and the amount of money spent by women on all kinds of supplements and therapies that have not been tested at all or have been tested and found to be not helpful for menopausal symptoms. It behooves us to do better by women. We are increasing teaching about menopause at University of Auckland medical school and developing a short course to upskill and train General Practitioners in menopause care.”

No conflicts of interest declared.

The Australian SMC also gathered independent expert comments.

Gino Pecoraro OAM, Associate Professor of Obstetrics and Gynaecology at the University of Queensland; President of the National Association of Specialist Obstetricians and Gynaecologists (NASOG); and a practising obstetrician and gynaecologist in private practice in Brisbane, comments:

“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 non-pharmacological treatments to help sufferers better deal with this transition. However, there remains a place for symptom control with hormonal and non-hormonal 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?”

Conflict of interest statement: “Gino has given presentations for a wide range of pharma companies that make HRT products and has run workshops and lectures for GPs that have been organised and funded by multiple pharma companies.”

Professor Jayashri Kulkarni, Director of HER Centre Australia at Monash University, comments:

“Menopausal mental ill health can be serious and debilitating for many women. Women’s lives are busy and complex but the hormone changes in the brain can be a ‘tipping factor’ causing anxiety, depression and ‘brain fog’. Of course most women do not experience adverse mental health issues related to menopause, but there is a significant group of women who experience severe depression, anxiety and brain fog that impairs their functioning at work or in their relationships.

“There is considerable brain biology research showing the impact of fluctuating gonadal hormones changing brain chemistry and circuitry causing mental ill health. Population surveys are the wrong method to tackle menopause mental illness. Hormone therapy has been shown clinically to be effective in treating menopausal mental ill health thereby helping women resume a good quality of life.

“Women with menopause-related mental illness demand and deserve better treatment than standard antidepressants that only provide partial respite. The voice of these women must be heard, and effective treatments must be offered to her, so she can make an informed decision about her best options.”

No conflicts of interest declared.

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