Menopause Live (16 January, 2012) from IMS

The use of hormone therapy (HT) by menopausal women declined by about two-thirds after the publication of the Women’s Health Initiative Study in 2002. In order to evaluate how the WHI influenced women’s knowledge, attitudes and perceptions towards HT use, as well as to find out their specific concerns and sources of information, Tao and colleagues [1] reviewed 11 qualitative studies (n = 566) and 27 quantitative studies (n = 39,251). Using meta-synthesis methods, they reviewed the qualitative studies and surveys and performed content analysis on the study reports. They pooled the quantitative studies using a random-effects meta-analysis. By applying a meta-synthesis approach, they feel that these findings are broadly applicable across large groups of patients. They report that women are positive about the use of menopausal hormone therapy (MHT) for symptom control, prevention of osteoporosis and improved quality of life. Concerns exist about potential harmful effects, particularly cancer risks. Sources of information include health providers, media, and social contacts. Media, as a source of information, is often valued as equivalent to health providers. Women in the developing world have less access to alternative sources of information than women in industrialized countries, a fact that concerns the authors.

Comment
That health-care providers are in fierce competition with the hairdresser, the woman on the next yoga mat, and the tabloid press as well as the Washington Post for credibility when it comes to ‘hormones’ is well known to those of us dealing with menopausal patients in our daily practice. It is also not surprising that, while women find that MHT improves their quality of life, they are worried that they will get breast cancer from it. But it is still nice to have this formally documented. 

However, it is disturbing that the authors seem to take it for granted, without any questions whatsoever, that MHT is inherently risky and that especially obstetrician/gynecologists [2], brainwashed by the pharmaceutical industry [3], are in denial regarding those risks. They state ‘…in 2011, the widespread use of HT seems misguided...”, referring for this blanket assessment to position statements by the International, Asian-Pacific, European and North American Menopause Societies from 2005. They seem unaware, that (a) this never was the position of the International Menopause Society in the first place, and (b) that the three other menopause societies, and even lead authors of the WHI themselves, have all revised their original statements by 2011 to a more nuanced and overall more positive view regarding the risks and benefits of MHT [4-8]. The authors also seem not to be familiar with an emerging body of literature on the negative consequences of the drastic decline in MHT use after publication of the WHI. One such study [8], including 80,955 postmenopausal women and showing a 55% increase in hip fracture risk by 2008 in the women who abandoned their MHT in the wake of the media-generated WHI panic after 2002, was recently reviewed in Climacteric by Gambacciani [9]. 

The updated positions of the leading menopause societies and current research undercut Tao and colleagues’ assertion that MHT is best avoided or at least limited. Their discussion reminds us that we not only have to inform our patients and the lay press better, but apparently our colleagues as well.

Regula Bürki
Hirslanden Hospital Group, Berne, Switzerland

References
1. Tao M, Teng Y, Shao H, Wu P, Mills EJ. Knowledge, perceptions and information about hormone therapy (HT) among menopausal women: a systematic review and meta-synthesis. PLoS One 2011;6:e24661.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0024661
2. Power ML, Anderson BL, Schulkin J. Attitudes of obstetrician-gynecologists toward the evidence from the Women’s Health Initiative hormone therapy trials remain generally skeptical. Menopause 2009;16:500–8.
http://www.ncbi.nlm.nih.gov/pubmed/19169162
3. Fugh-Berman A, McDonald CP, Bell AM, Bethards CE, Scialli RA. Promotional tone in reviews of menopausal hormone therapy after the Women’s Health Initiative: an analysis of published articles. PLoS Med 2011;8:e100425.
http://www.ncbi.nlm.nih.gov/pubmed/21423581
4. Sturdee DW, Pines A, on behalf of the International Menopause Society Writing Group. Updated IMS recommendations on postmenopausal hormone therapy and preventive strategies for midlife health. Climacteric 2011;14:302–20. (Adopted by the Asia Pacific Menopause Federation 2011).
http://www.ncbi.nlm.nih.gov/pubmed/21563996
5. Gompel A, Rozenberg S, Barlow DH; EMAS board members. The EMAS 2008 update on clinical recommendations on postmenopausal hormone replacement therapy. Maturitas 2008;61:227-32.
http://www.ncbi.nlm.nih.gov/pubmed/19028033
6. Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society.
http://www.menopause.org/PSht10.pdf
7. Taylor HS, Manson JE. Update in hormone therapy use in menopause. J Clin Endocrinol Metab 2011;96:255-64.
http://www.ncbi.nlm.nih.gov/pubmed/21296989
8. Karim R, Dell RM, Greene DF, Mack WJ, Gallagher JC, Hodis HN. Hip fracture in postmenopausal women after cessation of hormone therapy: results from a prospective study in a large health management organization. Menopause 2011;18:1172-7.
http://www.ncbi.nlm.nih.gov/pubmed/21775911
9. Gambacciani M. HRT misuse and the osteoporosis epidemic. Climacteric 2011 December 1. Epub ahead of print.
http://www.ncbi.nlm.nih.gov/pubmed/22132704

Scientific Editor: Amos Pines (apines@netvision.net.il)
Editorial Consultant: Jean Wright (jwright.ims@btopenworld.com)