What we can agree on about hrts and what we still don't have any idea about

Two interesting documents have recently been released that can make a difference to how we, and our doctors, think about and use hrts.



First is the Revised Global Consensus Statement on Menopausal Hormone Therapy. You can read the full version online here and here, and it's worth doing so because the language is clear and to the point, the article itself brief.



What this represents, as the article clearly states, is what a whole whack of international expert societies on menopause can all agree on. It may not cover everything each one specifically states, but it's the fundamentals they all accept as proven today. And that's important: these are proven points, not things still up for discussion or demonstration. And so if your doctor doesn't know these things or disagrees with them, he's disagreeing with what the specialists in the field accept as proven. There's always room for personalization, but if he's still arguing about this stuff and can't explain why it doesn't apply to you, you may be receiving outmoded care.



What's exciting for us in this? Mostly, that this includes a number of points we've been making for years.

The type and route of administration of MHT [Menopausal Hormone Therapy] should be consistent with treatment goals, patient preference and safety issues and should be individualized. The dosage should be titrated to the lowest appropriate and most effective dose.

Note the "patient preference" part in there. As well as the "most effective" in with the "lowest" point.

Duration of treatment should be consistent with the treatment goals of the individual, and the benefit/risk profile needs to be individually reassessed annually. This is important in view of new data indicating longer duration of VMS [hot flashes] in some women.

See what the main standard is there? the "treatment goals of the individual." That means that if we say we need it, we do. Yes, it's right to check this every year and try out a lower dose from time to time, but no longer is there any excuse for an arbitrary age or cumulative time cut-off.



And, finally:

The risk of breast cancer in women over 50 years of age associated with MHT is a complex issue with decreased risk reported from RCTs [clinical trials] for estrogen alone (CE [Premarin] in the Women’s Health Initiative (WHI)) in women with hysterectomy and a possible increased risk when combined with a progestin (medroxyprogesterone acetate in the WHI) in women without hysterectomy. The increased risk of breast cancer thus seems to be primarily, but not exclusively, associated with the use of a progestin with estrogen therapy in women without hysterectomy and may be related to the duration of use.

Note that although they identify the one progestin that there's solid clinical data for, they leave the question somewhat open. Thus we begin to see that the risk of all progestogens is gaining in credibility. "Just because" is no longer sustainable in hrt prescribing, especially for women who have had a hysterectomy.



Here's the full citation and doi number if you want to share this and it's not convenient to download one of the pdf versions linked above:

Climacteric

ISSN: 1369-7137 (Print) 1473-0804 (Online) Journal homepage: http://www.tandfonline.com/loi/icmt20

Revised Global Consensus Statement on Menopausal Hormone Therapy

T. J. de Villiers, J. E. Hall, J. V. Pinkerton, S. Cerdas Pérez, M. Rees, C. Yang & D. D. Pierroz

To cite this article: T. J. de Villiers, J. E. Hall, J. V. Pinkerton, S. Cerdas Pérez, M. Rees, C. Yang &

D. D. Pierroz (2016): Revised Global Consensus Statement on Menopausal Hormone Therapy,

Climacteric, DOI: 10.1080/13697137.2016.1196047

To link to this article: http://dx.doi.org/10.1080/13697137.2016.1196047

Could precision prescribing of estrogen be achieved?

This is the second interesting article, one that one of the members of our discussion group just shared with us all: Post NICE Guidelines: could precision prescribing of estrogen be achieved?



In a way, this article also says the things we've been saying for years about the fact that while the drug information data for hrts suggests that they are drugs of a "one size fits all" sort, personal experience of women is varied and confusingly individualized. In short, it basically says that different women have different needs and to best meet them, you need to give them different things. And by the way, lab tests are rubbish at figuring all of this out.



Groundbreaking stuff, this.



Okay, while we'd like to just be snotty along the lines of it being about time doctors were catching on to what women have been trying to tell them for so long, it's actually good, in the ponderous, over-proven way that medical consensus moves, that these things are being said. Again. Because if we say it, we're just poor ignorant deluded women; if doctors say it, it is thought-provoking and reasonable...and may eventually make a difference. And that's the real importance of this article: that doctors are saying that there's more to using or prescribing hrt than thinking of it as an interchangeable drug.



Also, we wanted to throw up our hands and cheer at this paragraph—or, actually groan with the truth of it:

The NICE guidelines have been published at a time when investment in research into women's health has evaporated, not only because of desertion of commercial money but fundamentally because the funding in this area of research is not attractive for voters and, indeed, many opinion leaders in those policy-making circles believe that the menopause and its associated symptoms are women's destiny and they have to cope with it.

We don't entirely like his conclusion that women should fund this needed research, but we have a sneaking suspicion that we're looking, right here, at the future of medical research: if you want it, you have to invest in it. And when haven't we women, in the end, had to do things for ourselves?