QUALITY OF LIFE AND MENOPAUSE
The perception of menopause and its impact on quality of life vary in different areas of the world 1-5. In some places, menopause leads to a higher social status, in others – not. The forum agreed that the issue of quality of life is pivotal for any discussion on menopause management and the evaluation of the benefits versus the risks of HRT.
Quality of life may be defined in many ways, based on medical, cultural and social parameters, but is largely subjective and therefore not easy to evaluate under a global, unified scale. Some may say that menopause is just a physiological stage during a woman’s life cycle and therefore its associated adverse consequences of quality of life should not be medicalized. Others may argue that the risks of HRT do not justify its use unless quality of life is substantially compromised. The negative sentiments coming from the WHI publications and the related media coverage intimidate women and health-care providers and in a way lead to confusion and to a degraded credibility of the medical profession over these issues, but the WHI Quality of Life analysis started with only 11% of subjects who had moderate or severe hot flushes and did not have the power to determine a comparative improvement in the treatment vs. placebo group 6. Such a low incidence of climacteric symptoms is not representative of the healthy peri- and early postmenopausal women treated in everyday practice.
· In symptomatic postmenopausal women, quality of life and sexuality are improved by HRT 7,8 and, in the presence of symptoms of androgen deficiency, by additional androgen administration.
· In some cultures, and for some women, vaginal bleedings are unacceptable; if bleeding cannot be eliminated, alternatives to HRT may be used.
· There is no evidence that so-called ‘natural’ products and unregulated hormone products (compounded bio-identical) significantly improve quality of life.
PERCEPTIONS VS. SCIENTIFIC DATA (THE ‘EVIDENCE’)
HRT, coronary heart disease, stroke and thromboembolism
Perceptions
· HRT increases coronary heart disease (CHD) risk throughout the whole
postmenopausal period.
· HRT causes an increase in coronary events in the first 1–2 years in all women.
· Stroke risk is substantially increased in women receiving HRT.
· The risk of both venous and arterial thromboembolism is increased during HRT.
The evidence
· HRT in women aged 50–59 years does not increase CHD risk in healthy women and may even decrease the risk in this age group 9. [A]
· Estrogen-alone therapy in the age group 50–59 was associated with significantly less coronary calcification (equivalent to a smaller plaque burden), which is consistent with findings of a lower coronary intervention score in women of this age in the WHI study 10. [A]
· Early harm (more coronary events during the first 2 years of HRT) was not observed in the early postmenopausal period. The number of CHD events decreased with duration of HRT in both WHI clinical trials 11. [A]
· Data derived from randomized controlled trials in the age group 50–59 are similar to the older observational data suggesting a protective effect of HRT on coronary disease 9,12. [A, B]
· It is unclear at present whether there is a statistical increase in ischemic stoke with standard HRT in healthy women aged 50–59. The WHI data showed no statistically significant increase in risk; nevertheless, even if statistically increased, as found in the Nurses’ Health Study, the low prevalence of this occurrence in this age group makes the attributable risk extremely small 13,14. [A,B]
· The risk of venous thrombosis is approximately two-fold higher with standard doses of oral HRT, but is a rare event in that the background prevalence is extremely low in a healthy woman under 60 years of age15. [A]
· The risk of venous thrombosis is possibly less with transdermal, compared with oral estrogen therapy16. [B]
Breast
Perceptions
· All types of HRT cause an increased risk of breast cancer within a short duration of use.
· HRT causes an increase in mortality from breast cancer.
· The reported decline in breast cancer rates in the US following the publication of the WHI proves that HRT causes cancer.
· HRT causes an increase in mammographic breast density.
· Increase in mammographic breast density is associated with an increased risk of breast cancer.
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