Managing Menopause: A new review by WCH physicians

May 15, 2023

Menopausal symptoms may occur up to 10 years before the last menstrual period and can last more than 10 years, with negative effects – hot flashes, night sweats, sleep disturbances – for many people. A recently published review by Women’s College Hospital physicians Dr. Iliana Lega and Dr. Michelle Jacobson, summarized the evidence for treating menopausal symptoms with a careful discussion of the risks and benefits, to help guide clinicians in evaluating and treating women during the menopausal transition. 

Drs. Lega and Jacobson spoke about this research and why it’s important to address gaps in menopausal education and care, and reduce stigma around menopause.

Dr. Iliana Lega and Dr. Michelle Jacobson

1. How can we improve knowledge and comfort among physicians to provide menopausal care (including prescribing HRT)? And what are the next steps?

Currently, there is very little focus on menopausal care, especially as it relates to hormone therapy, essentially due to an entire generation of clinicians not having received adequate training in this area and therefore not feeling comfortable prescribing hormone therapy given fears and misinformation about it.

To address these gaps in education, we need to do the following:

  • First and foremost, education about menopausal care and hormone therapy needs to be re-added and re-emphasized at the undergraduate medical curriculum level with lectures and small group sessions focusing on providing this care.
  • Second, education needs to be improved at the resident/post-graduate level (especially family medicine, gynecology, urology and internal medicine training programs) with both lectures and also clinical rotations where residents become familiar with providing menopausal care. For example, in Endocrinology and Gynecology at the University of Toronto, we have set up dedicated fellowships in Menopause and Women’s Health so that trainees can receive the education and exposure they need to feel comfortable providing menopausal care once they go out into practice. More programs like this, especially for physicians trained in primary care are needed.
  • Finally, there is an ongoing need for continuing medical education activities for physicians in practice, including conferences, lectures and educational materials.

2. Why is this review important?

The reason Dr. Jacobson and I decided to write this review is because we saw that there was a tremendous gap when it comes to providing menopausal care to women. Many women do not seek care for menopausal symptoms, assuming there are no safe treatments, and that they must simply endure this ‘natural’ process.  Most of this gap in care is due to the findings of the Women’s Health Initiative (WHI) hormone trial published in 2002, which found that women randomized to hormone therapy had a higher risk of breast cancer, stroke and heart disease. These results were widely taken up by the media and press, and by 2007, prescriptions for hormone therapy dropped by 70 per cent with a clear message among patients and clinicians that hormone therapy is dangerous. 

It turns out that there were significant flaws with this study, most importantly that age matters and there is a window of opportunity where the benefits of starting hormone therapy greatly outweigh the risks. The risk of stroke and heart disease reported in the WHI, for instance, were mostly among women who started hormone therapy after age 60 and into their 70s. Re-analysis of the initial WHI by age, as well as newer studies since, show that hormone therapy is not associated with an increased risk of heart disease in younger women (50 to 60 years of age), and in fact it might even be protective. The absolute risk of stroke in younger menopausal women is also very low, as is the risk of breast cancer. As such the very small risks of hormone therapy need to be weighed against all the potential benefits (for instance, improvement in quality of life, reduced risk of fracture and reduced risk of diabetes).

The goal of our review is to provide a clear, clinical summary of the risks and benefits of menopausal therapies so that clinicians feel comfortable reviewing menopausal treatment options. While not all women may choose or be eligible for hormone therapy, all women should be counseled on possible treatment options so they can make an informed decision on what works best for them.

3. How can we ensure patients are empowered with knowledge and better access to menopausal care? 

Clinicians need to be better informed and more comfortable starting the conversation about available treatment options for menopausal symptoms. In my opinion, all women, once they enter their 40s, should be screened for menopausal symptoms. Starting the conversation with patients provides them with an opportunity to discuss symptom burden and explore treatment options. Furthermore, this empowers women with knowledge and information about menopause, which they can take back to their peer group and family members and further increase the dissemination of knowledge around menopause.

There also needs to be a massive shift in the public’s perception on the safety of hormone therapy, which unfortunately has not caught up with the most recent studies showing its safety in younger menopausal women. Given the fall out from the WHI study, there is still a pervading attitude in the media and among the lay public, and frankly among many physicians too, that hormone therapy is dangerous, full stop. Fortunately, there has been recent media coverage, which is trying to correct this, as well as books written by reputable public figures that also attempt to provide women with correct information about the overall safety of these treatments.  

4. As you mentioned, we’ve seen a recent uptick in media and conversation around menopause. Why is it important to remove the stigma around menopause? How can physicians contribute to removing stigma?

I am so excited to see that menopause is being frequently talked about in the media these days – it’s fantastic and so important. The news and media speak to non-medical people, essentially patients, who also need to be educated about the overwhelming safety of hormone therapy in most cases. This uptick in media conversations about menopause is also key because it normalizes menopause as well as the available treatment options, thereby leading to an environment where women feel it is safe and welcome to discuss their symptoms instead of simply suffering in silence.

Unfortunately, there is also a certain degree of sexism that persists in our society and medical system that has led to many generations of women suffering in silence. A recent New York Times article highlighted the vast undertreatment of menopause, with the authors describing a hypothetical scenario whereby men experience the multitude of symptoms, including sexual dysfunction, only to be reassured by their clinicians that these symptoms are “normal” and then not offered any of the existing safe and effective treatments. The authors comment that such a scenario seems absurd and unlikely, however it aptly describes the current state of menopausal care with less than 50 per cent of menopausal women seeking care, and up to 75 per cent of women not receiving any medical treatment for their bothersome menopausal symptoms.

Physicians can further contribute to normalizing the discussion of menopause by initiating the conversation during clinical encounters. Instead of waiting for women to present with symptoms that they may have been enduring for months or years, clinicians can and should start the conversation as soon as a woman enters her 40s. By having these discussion early, women will be empowered with the knowledge they need to reduce their burden of menopausal symptoms.   

Thank you, Drs. Lega and Jacobson!