Reacción a "Reactions: article advocates empowerment model for managing menopause"

Four papers published pertaining to menopause in The Lancet are not about new research findings but offer opinions as to how menopause might be viewed and how the experience of menopause might be optimised. 

It is disappointing that the lead article states that 'the principles of health empowerment have not been applied to menopause' when empowerment of women to best navigate their menopause, through the provision of credible health information to support informed and shared decision-making, has been the focus of national and international organisations (such as the Australasian and International Menopause Societies and Jean Hailes for Women’s Health) for many years. 

The papers raise the important concern of potential misattribution of an array of psychological symptoms to menopause. While this is also not a new concept, it is consistent with other recently published reviews and highlighting this concern reinforces the message to women and clinicians not to blame every symptom on menopause.  

The authors stress that most women will not experience debilitating menopausal symptoms. Nevertheless, they acknowledge that 60-80% of women will have menopausal flushes and sweats that can last, on average, about 7 years, and that for 1 in 3 women these can be quite severe. 

The authors caution against 'over-medicalisation' of the menopause but the messaging regarding [hormone] therapy is mixed, and potentially confusing. For example, it is stated that 'The North American Menopause Society recommends specific MHT [menopausal hormone therapy], gabapentin and oxybutynin which have mild to moderate efficacy and reduce hot flushes by 1-2 per day with no significant improvement in menopause-related quality of life'.  But, further on it is stated that MHT is effective (reduces flushes by 2-4/day) and improves health-related quality of life. Of concern is the promotion of gabapentin and oxybutynin, neither of which are approved in any country for the treatment of menopausal flushes/sweats (vasomotor symptoms) and data for oxybutynin is notably scant.  In contrast fezolinetant, which has been approved in the UK, EU, Australia and the US specifically for vasomotor symptoms, has been downplayed to being only modestly effective despite robust evidence which is lacking for these other nonhormonal therapies.

The importance of bone loss at menopause is also recognised together with the effectiveness of MHT for fracture prevention, but other long-term effects of menopause on health are called to question. This conflicts with other highly regarded expert opinions [see here and here] and this in turn demonstrates that this Lancet series needs to be seen as only one interpretation of the published research. 

The authors seem determined to minimise the important role of MHT in helping many women as they reach menopause. They ignore other published systematic reviews which all agree that MHT is the most effective treatment for vasomotor symptoms, is as effective as other bone-specific therapies (antiresorptive agents) in reducing postmenopausal osteoporosis and associated fractures and, unlike some antiresorptives, is not associated with an increased risk of fracture upon stopping treatment.

Current guidance from international and national menopause societies, including Australia and New Zealand all speak to empowerment of every woman at this pivotal stage of her life. They also stress the importance of an evidence-based approach and, importantly, offering each woman the care, support and, where required, treatment she seeks to help her on her journey.

Nonetheless, in general these papers align with, and support the latest internationally and nationally endorsed best practice guidance for menopause published in 2023, Practitioner Toolkit for Managing Menopause, with open online access for women and clinicians to facilitate health empowerment, as recommended by these papers.