Dr Jana Combrinck, GP, and Dr Kym Jones, Gynaecologist, Joondalup
Attending the 19th Annual IMS Congress last year, we gained insights into the latest developments in menopause
Breast cancer risk is one of the most common concerns expressed by both patients and healthcare practitioners when discussing menopausal hormone therapy (MHT).
Professor Robert Langer, one of the principal investigators of the Women’s Health Initiative (WHI) trial, helped clarify several misconceptions about MHT. The WHI study, which contributed to widespread fear, suggested that oestrogen and progestin (CEE+MPA) increased breast cancer risk.
However, Professor Langer emphasised that the breast cancer outcomes in the study were not statistically significant, as breast cancer was a secondary outcome – not the primary outcome the study was designed to measure.
As breast cancer typically starts developing 7-12 years before a detectable mass, the increased rates of breast cancer three years into the WHI study cannot be directly attributed to MHT.
While synthetic progestins like MPA can mildly stimulate breast tissue, micronised progesterone – now the preferred option – has a neutral effect on breast cancer risk. Additionally, oestrogen, particularly when used alone, has been shown to reduce breast cancer risk.
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For patients who are concerned about breast cancer, emphasise that lifestyle factors such as height, diet, and alcohol consumption, have a greater impact on breast cancer risk than MHT.
Managing bleeding during the menopausal transition
Professor Steven Goldstein’s talk on bleeding in the menopausal transition emphasised the importance of using transvaginal ultrasound as the first step when investigating postmenopausal bleeding.
If the endometrial thickness is under 4mm, further investigation via endometrial biopsy is usually unnecessary and unreliable at excluding pathology. For women experiencing erratic bleeding during perimenopause, Goldstein suggested that a low dose combined contraceptive pill may be more beneficial than MHT.
By suppressing ovarian function and providing a stable hormone level, it can improve psychosocial symptoms like irritability and brain fog, as well as provide effective contraception. Low-dose contraceptives can be used up to age 50 in low-risk women.
MHT in osteoporosis prevention
Professor Bronwyn Stuckey’s presentation highlighted the critical role of oestrogen in bone health, describing it as “nature’s gift to bones”.
The menopausal transition represents a unique window of opportunity to use MHT to prevent bone loss and fractures, which significantly impact women’s quality of life. The maximal benefit from MHT occurs when started early in the transition and continued for a prolonged period, offering gains of up to 20% improvement in BMD.
Dr Tobie De Villiers’ talk changed our approach to osteoporosis risk assessment. He argued FRAX is not particularly useful in women under 65 and that primary healthcare providers should feel confident offering DEXA scans to women in perimenopause to assess bone density.
Testosterone therapy in postmenopausal women
Interest beyond treatment of hypoactive sexual desire disorder is growing. However, large studies have found no significant benefits for well-being, bone density, major depression, cognitive decline or lean mass.
When considering a diagnosis of HSDD we are encouraged to use the Decreased Sexual Desire Screening Questionnaire to exclude other factors which may contribute to decreased sexual desire.
MHT and the management of vaginal dryness is an important first step. Experts agree that total serum testosterone should be used for screening and treatment is aimed at pre-menopausal female testosterone levels.
Androfeme 1 (testosterone 1% cream in 50ml) is the only approved testosterone formulation for women in Australia. A clear and concise guide to starting and maintaining treatment are available from the manufacturer on request.
Discontinue treatment if there has been no improvement at six months, assuming therapeutic levels. It does not need to be weaned.
Key messages
- Concerns about breast cancer with menopausal hormone therapy have been overstated
- DEXA scans can be offered to women under 65 to assess bone density
- Genitoutrinary syndrome of menopause impacts quality of life but is under recognised
Genitourinary syndrome of menopause
All experts agreed that GSM is a prevalent yet under-recognised condition that significantly impacts quality of life. Topical oestrogen and DHEA therapy play key roles in symptom relief and vaginal health restoration.
While vaginal lubricants and moisturisers provide short-term symptom relief, the first-line treatment remains topical vaginal oestrogen. Topical oestrogen has not been found to improve prolapse or urge incontinence, nor have an effect on nerve-endings, but it has been shown to improve stress incontinence, prevent recurrent UTIs and reduce dyspareunia.
DHEA is synthesised by the adrenal glands and ovaries as an inactive precursor, then converted intracellularly to active hormones (oestrogens and androgens).
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Relatively new to the market is the ‘biodentical’ DHEA vaginal pessary containing prasterone (6.5mg) that can lower the vaginal pH, improve dyspareunia and decrease vaginal dryness. Vaginal DHEA is seen to provide targeted treatment without the systemic effects.
Other therapies for GSM, include vaginal laser such as fractionated CO2 laser and erbium laser, which works by causing microdamage in vaginal layers to promote collagen remodeling and neovascularization. It is seen as effective for vulvovaginal atrophy, but long-term safety and efficacy data is lacking.
Author competing interest – the authors were sponsored to attend the conference by Lawley Pharmaceuticals and Besins.
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