Impact of hormone therapy on quality of life after menopause

From cardiovascular protection to cardiovascular risk: the metamorphosis of menopausal hormone therapy

Over the last 70years, oestrogen therapy for the management of menopausal symptoms has undergone a metamorphosis from perceived cardiovascular protection to perceived cardiovascular risk. The former perception is based on the convincing evidence from the Nurses' Health Study cohorts and the epidemiological data surrounding early menopause. The latter, and later, perception is based on the disquieting results from two randomised controlled studies, the Heart and Estrogen/Progestin Replacement Study (HERS) and the Women's Health Initiative study (WHI). The reality is probably more nuanced than the conclusions presented by any of these studies. When face to face with a patient, the clinician must negotiate the appropriate decision pathway around the interaction between cardiovascular risk, cardiovascular disease, menopause, and oestrogen +/-progestogen-containing hormone therapy.

Effectiveness and safety of menopause treatments: pitfalls of available evidence and future research need

By 2050 more than 1.6 billion women worldwide will be of post-reproductive age, with >75% reporting severe menopausal symptoms. The last few years saw a gradual uplift in public awareness reaffirming the health needs of women with menopause. Still, effective translation of available evidence on menopause treatments is hindered by several methodological limitations and poor research conduct. We argue that a paradigm shift is required in menopause research to address the remaining knowledge gap and guide safe evidence-based care provision. A critical misconception across studies on menopause is the assumption that women represent a homogeneous group who respond similarly to a particular therapy irrespective of their exposure and individual risk factors. We highlight potential solutions to optimize the quality of future research in menopause including adopting robust trial methodology, standardize outcome reporting to capture quality-of-life measures, and improve lay patient and public involvement in future research.

A cross-sectional study of symptoms and health-related quality of life in menopausal-aged women in China

OBJECTIVE

To measure symptoms and health-related quality of life in a cross-sectional cohort of menopausal-aged women in China.

METHOD

A cross-sectional survey was conducted in a general population cohort of 2,000 Chinese females over the age of 45 years. Patients completed the Chinese version of the EuroQol-5D five level (EQ5D5L) health-related quality of life instrument via Personal Digital Assistant. Raw scores were converted to utility tariffs using value sets for China. Statistical analysis included Pearson's chi-square test, z test for multiple comparisons with adjustment by the Bonferroni method, independent-sample t-test, ANOVA, and adjustment by the Tukey method for multiple comparison. Results were considered statistically significant when p < 0.05 and the study was reported according to the STROBE recommendations.

RESULTS

In a cohort of 2000 women, 732 (37%) were premenopausal, 798 (40%) were perimenopausal and 470 (23%) were postmenopausal. Perimenopausal women reported significantly more symptoms (91%) compared to premenopausal (77%) and postmenopausal (81%) women. Health-related quality of life was significantly lower in symptomatic perimenopausal women compared to premenopausal (0.919, p < 0.05) and postmenopausal (0.877, p < 0.05) women. Within each group there was a statistically significant difference between the health-related quality of life of women with symptoms compared to without symptoms.

CONCLUSION

The perimenopausal phase of menopause is associated with significantly more symptoms and significantly lower HRQoL compared to premenopausal and postmenopausal phases.

Combination of Soy Isoflavones, 8-Prenylnaringenin and Melatonin Improves Hot Flashes and Health-Related Quality of Life Outcomes in Postmenopausal Women: Flavie Study

OBJECTIVES

This study aims to investigate the effects of a combination of soy isoflavones, 8-prenylnaringenin (8-PN), and melatonin in postmenopausal women suffering from moderate-to-severe hot flashes (HFs).

METHODS

A multicenter, prospective, open-label study enrolled 44 postmenopausal women suffering from moderate-to-severe HFs (≥ 5 daily or ≥ 35 weekly) to receive 54.4 mg standardized soy isoflavones (including 24.5 mg genistein and 16.3 mg daidzein), 100 µg 8-PN, and 1 mg melatonin once daily for 12 weeks. The primary clinical outcomes included changes in health-related quality of life (HRQoL) scores (Menopause-Specific QoL questionnaire [MENQoL] and Cervantes Scale) and HFs following 4 and 12 weeks of treatment. Other analyses included treatment adherence, acceptability, tolerability, and safety.

RESULTS

All of the four domains of MENQoL questionnaire significantly improved at 4 weeks (P < 0.05) and 12 weeks (P < 0.001), affecting significantly the vasomotor, psychosocial, and physical spheres (41.2%, 26.3%, and 25.0%; 12 weeks improvements, respectively). Similarly, in the menopause (39.3%) and psychic (51.7%) domains (both P < 0.05 at 12 weeks), the global score of the Cervantes Scale significantly increased at 4 weeks (18.6%) and 12 weeks (35.4%). Accordingly, moderate-to-severe HFs significantly decreased at 4 weeks compared to baseline (41.7% reduction) and further reduced at 12 weeks (76.5%), including the total number of episodes.

CONCLUSIONS

Food supplements containing soy isoflavones, 8-PN, and melatonin showed an early and progressive benefit for reducing clinically significant HFs and for improving HRQoL across all domains, favorably affecting postmenopausal women's overall well-being.

A multicenter, randomized, placebo-controlled study to select the minimum effective dose of estetrol in postmenopausal participants (E4Relief): part 2-vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life

OBJECTIVE

A phase 2 study showed that 15 mg estetrol (E4) alleviates vasomotor symptoms (VMS). Here, we present the effects of E4 15 mg on vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life.

METHODS

In a double-blind, placebo-controlled study, postmenopausal participants (n = 257, 40-65 y) were randomized to receive E4 2.5, 5, 10, or 15 mg or placebo once daily for 12 weeks. Outcomes were the vaginal maturation index and maturation value, genitourinary syndrome of menopause score, and the Menopause Rating Scale to assess health-related quality of life. We focused on E4 15 mg, the dose studied in ongoing phase 3 trials, and tested its effect versus placebo at 12 weeks using analysis of covariance.

RESULTS

Least square (LS) mean percentages of parabasal and intermediate cells decreased, whereas superficial cells increased across E4 doses; for E4 15 mg, the respective changes were -10.81% ( P = 0.0017), -20.96% ( P = 0.0037), and +34.17% ( P < 0.0001). E4 15 mg decreased LS mean intensity score for vaginal dryness and dyspareunia (-0.40, P = 0.03, and -0.47, P = 0.0006, respectively); symptom reporting decreased by 41% and 50%, respectively, and shifted to milder intensity categories. The overall Menopause Rating Scale score decreased with E4 15 mg (LS mean, -3.1; P = 0.069) and across doses was associated with a decreasing frequency and severity of VMS ( r = 0.34 and r = 0.31, P < 0.001).

CONCLUSIONS

E4 demonstrated estrogenic effects in the vagina and decreased signs of atrophy. E4 15 mg is a promising treatment option also for important menopausal symptoms other than VMS.

Menopause hormone therapy and complementary alternative medicine, quality of life, and racial/ethnic differences: the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

We hypothesized that, among midlife women with vasomotor and/or genitourinary symptoms of menopause, (1) hormone therapy (HT) compared with complementary alternative medicine (CAM) will be associated with higher quality of life (QoL), and (2) race/ethnicity would modify associations of HT and CAM with QoL.

METHODS

Cross-sectional and longitudinal analyses of QoL in the Study of Women's Health Across the Nation participants using HT, CAM, or both. Women ( n = 2,514) completed a CAM use questionnaire and QoL assessments at baseline and every 1 to 2 years from 2002 to 2013. Associations between QoL and treatment, adjusted for covariates, and race/ethnicity-by-treatment interactions were analyzed using linear and mixed effects regression models.

RESULTS

During 7.8 (SD, 2.9) years of follow-up, 732 women (29%) reported HT of 2.4 (SD, 1.7) years, and 798 women (32%) reported CAM use of 2.1 (SD, 1.4) years. Overall, neither HT nor CAM was associated with QoL. However, the treatment-by-race/ethnicity interaction was significant for self-reported QoL ( P = 0.034 at baseline, P = 0.044 longitudinal). Among White women, self-reported QoL was higher in HT-only users than in those who used neither ( P = 0.030; d = 0.11; 95% confidence interval, 0.01-0.21). In contrast, Black women using HT only had lower self-reported QoL compared with Black women using neither ( P = 0.027; d = -0.21; 95% confidence interval, -0.40 to -0.02).

CONCLUSION

Comparisons between treatment type within each racial/ethnic group yielded significant differences in self-reported QoL. Clinicians should be aware of racial/ethnic differences in treatment preferences when counseling patients on treatment options for menopausal symptoms to provide optimal care.

VIDEO SUMMARY

http://links.lww.com/MENO/B33 .

Menopause and work: A narrative literature review about menopause, work and health

BACKGROUND:

Menopause is part of working women’s lives. In Western countries, labour market patterns are changing rapidly: women’s labour participation has increased, the percentage of full-time working women is rising, and retirement age is increasing.

OBJECTIVE:

This narrative literature study aims to provide an insight in the state of the art in the literature about the relationship between menopause, work and health and to identify knowledge gaps as input for further research.

METHODS:

The search was conducted in PubMed, CINAHL, MEDLINE and ScienceDirect. The final set includes 36 academic articles, 27 additional articles related to the topic and 6 additional sources.

RESULTS:

Research on menopause, work and health is scarce. Results are grouped thematically as follows: Menopause and (1) a lack of recognising; (2) sickness absence and costs; (3) work ability; (4) job characteristics; (5) psychosocial and cultural factors; (6) health; (7) mental health, and (8) coping and interventions. Work ability of women with severe menopausal complaints may be negatively affected.

CONCLUSIONS:

Due to taboo, menopause remains unrecognised and unaddressed within an organisational context. New theoretical and methodological approaches towards research on menopause, work and health are required in order to match the variety of the work contexts world-wide.

A 16-week multicomponent exercise training program improves menopause-related symptoms in middle-aged women. The FLAMENCO project randomized control trial

OBJECTIVE

To investigate the influence of a supervised multicomponent exercise training program on menopause-related symptoms, particularly vasomotor symptoms (VMS), in middle-aged women.

METHODS

A total of 112 middle-aged women (mean age 52 ± 4 y old, age range 45-60 y) from the FLAMENCO project (exercise [n = 59] and counseling [n = 53] groups) participated in this randomized controlled trial (perprotocol basis). The exercise group followed a multicomponent exercise program composed of 60-minute sessions 3 days per week for 16 weeks. The 15-item Cervantes Menopause and Health Subscale was used to assess the frequency of menopause-related symptoms.

RESULTS

After adjusting for body mass index and Mediterranean diet adherence, the subscales measuring menopause-related symptoms and VMSs decreased 4.6 more in the exercise group compared to the counseling group (between-group differences [B]: 95% CI: -8.8 to -0.2; P  = 0.040). The exercise group also showed significant improvements in the subscales of couple relationships (between-group differences [B]: -1.87: 95% CI: -3.29 to - 0.45; P  = 0.010), psychological state (between-group differences [B]: -2.3: 95% CI: -5 to -0.2; P  = 0.035), and VMSs (between-group differences [B]: -4.5: 95% CI: -8.8 to -0.2; p  = 0.040) in the Cervantes Menopause and Health Subscale compared with the counseling group.

CONCLUSIONS

A 16-week multicomponent physical exercise program showed a positive effect on menopause- related symptoms especially in couple relationships, psychological state, and VMS, among 45 to 60 year old women.

Care reality of menopausal women in Germany: healthcare research using quantitative (SHI claims data) and qualitative (survey) data collection

PURPOSE

The transition from the fertile phase of life to menopause is associated with numerous physical changes. Hormone replacement therapy (HRT), as the most effective and efficient form of drug treatment, involves the use of oestrogens and progestins with the aim of increasing health-related quality of life through symptom reduction, sleep improvement and affect enhancement.

METHODS

The medical care situation and disease burden of menopausal women was investigated by means of a survey of 1000 women aged 45-60 years on the topics of quality of life, menopause and HRT and a quantitative, longitudinal healthcare study based on an anonymised and age- and sex-adjusted Statutory Health Insurance (SHI) routine data set with approximately four million anonymous insured persons per year.

RESULTS

Out of more than half a million women aged 35-70 years, and with statutory health insurance, (n = 613,104), 14% (n = 82,785) had climacteric disorder documented as a first diagnosis in 2014. The proportion of women with the climacteric disorder, who were prescribed HRT on an outpatient basis, was 21%; according to the forsa survey, 50% of the women surveyed felt moderate to poorly/very poorly informed about treatment options.

CONCLUSION

Findings from the health insurance research conducted with different data sources (survey and SHI claims data) indicate the need for increasing awareness and providing an early and informative education on HRT and its risks and benefits.

Hormone therapy in the postmenopausal years: considering benefits and risks in clinical practice

BACKGROUND

Menopausal symptoms can be very distressing and considerably affect a woman's personal and social life. It is becoming more and more evident that leaving bothersome symptoms untreated in midlife may lead to altered quality of life, reduced work productivity and, possibly, overall impaired health. Hormone therapy (HT) for the relief of menopausal symptoms has been the object of much controversy over the past two decades. At the beginning of the century, a shadow was cast on the use of HT owing to the concern for cardiovascular and cerebrovascular risks, and breast cancer, arising following publication of a large randomized placebo-controlled trial. Findings of a subanalysis of the trial data and extended follow-up studies, along with other more modern clinical trials and observational studies, have provided new evidence on the effects of HT.

OBJECTIVE AND RATIONALE

The goal of the following paper is to appraise the most significant clinical literature on the effects of hormones in postmenopausal women, and to report the benefits and risks of HT for the relief of menopausal symptoms.

SEARCH METHODS

A Pubmed search of clinical trials was performed using the following terms: estrogens, progestogens, bazedoxifene, tibolone, selective estrogen receptor modulators, tissue-selective estrogen complex, androgens, and menopause.

OUTCOMES

HT is an effective treatment for bothersome menopausal vasomotor symptoms, genitourinary syndrome, and prevention of osteoporotic fractures. Women should be made aware that there is a small increased risk of stroke that tends to persist over the years as well as breast cancer risk with long-term estrogen-progestin use. However, healthy women who begin HT soon after menopause will probably earn more benefit than harm from the treatment. HT can improve bothersome symptoms, all the while conferring offset benefits such as cardiovascular risk reduction, an increase in bone mineral density and a reduction in bone fracture risk. Moreover, a decrease in colorectal cancer risk is obtainable in women treated with estrogen-progestin therapy, and an overall but nonsignificant reduction in mortality has been observed in women treated with conjugated equine estrogens alone or combined with estrogen-progestin therapy. Where possible, transdermal routes of HT administration should be preferred as they have the least impact on coagulation. With combined treatment, natural progesterone should be favored as it is devoid of the antiapoptotic properties of other progestogens on breast cells. When beginning HT, low doses should be used and increased gradually until effective control of symptoms is achieved. Unless contraindications develop, patients may choose to continue HT as long as the benefits outweigh the risks. Regular reassessment of the woman's health status is mandatory. Women with premature menopause who begin HT before 50 years of age seem to have the most significant advantage in terms of longevity.

WIDER IMPLICATIONS

In women with bothersome menopausal symptoms, HT should be considered one of the mainstays of treatment. Clinical practitioners should tailor HT based on patient history, physical characteristics, and current health status so that benefits outweigh the risks.

Hand grip strength and health-related quality of life in postmenopausal women: a national population-based study

OBJECTIVE

Muscle strength progressively decreases after menopause. Hand grip strength (HGS) reflects overall muscle strength and may be associated with health-related quality of life (HRQoL). We aimed to assess the association between HGS and HRQoL in postmenopausal women.

METHODS

We used nationally representative data on 6,059 postmenopausal women from the Korea National Health and Nutrition Examination Survey (2014-2018). HGS was determined as the maximum value in kilograms (kg) achieved using either hand. HRQoL was estimated using the European Quality of Life Questionnaire-Five Dimensions (EQ-5D) questionnaire. The prevalence ratios of having moderate/severe problems on the EQ-5D were evaluated with adjustment for covariates using complex survey analysis.

RESULTS

The prevalence of having a problem in at least one of the HRQoL dimensions among postmenopausal women was 43.6%. Compared with participants with the lowest quintile of HGS, women in the highest quintile had a significantly lower prevalence of moderate/severe problems in most dimensions (fully adjusted prevalence ratios [95% confidence intervals]; 0.73 [0.60-0.89], 0.45 [0.28-0.72], 0.52 [0.38-0.71], 0.74 [0.63-0.87], and 0.91 [0.70-1.18] for mobility, self-care, usual activity, pain/discomfort, and anxiety/depression, respectively). The associations between HGS and EQ-5D index were stronger among the participants who were older (65-79 y), had a higher body mass index (≥ 25.0 kg/m2), had low physical activity, had a longer duration since menopause (≥ 10 y), and had a chronic disease.

CONCLUSIONS

Higher HGS was associated with a lower prevalence of moderate/severe problems in each dimension of the EQ-5D in postmenopausal women. These associations were more apparent in individuals who were older, had higher body mass index, or had a chronic disease.

Menopausal hormone therapy for women living with HIV

People living with HIV are ageing, and a growing number of women living with HIV are entering menopause. Women living with HIV commonly have bothersome vasomotor symptoms and onset of menopause at earlier ages; both factors go on to affect quality of life and systemic health. Vasomotor symptoms and early menopause are both indications for menopausal hormone therapy; however, current evidence suggests that this therapy is seldom offered to women living with HIV. Additionally, women living with HIV have several risks to bone health and are likely to benefit from the bone-strengthening effects of menopausal hormone therapy. We present an assessment of the benefits and risks of menopausal hormone therapy in the context of HIV care and propose a practical approach to its prescription. If considered in the appropriate clinical context with discussion of risks and benefits, menopausal hormone therapy might provide substantial benefits to symptomatic menopausal women living with HIV and improve health-related quality of life.

Effects of pharmacologic and nonpharmacologic interventions on menopause-related quality of life: a pooled analysis of individual participant data from four MsFLASH trials

OBJECTIVE

The Menopause Strategies: Finding Lasting Answers for Symptoms and Health network conducted three randomized clinical trials (RCTs) testing six interventions treating vasomotor symptoms (VMS), and also collected menopause-related quality of life (QOL) measures. A fourth RCT assessed an intervention for insomnia symptoms among women with VMS. We describe these seven interventions' effects on menopause-related QOL relative to control in women with VMS.

METHODS

We pooled individual-level data from 1,005 peri- and postmenopausal women with 14 or more VMS/week across the four RCTs. Interventions included escitalopram 10 to 20 mg/d; yoga/aerobic exercise; 1.8 g/d omega-3-fatty acids; oral 17-beta-estradiol 0.5 mg/d; venlafaxine XR 75 mg/d; and cognitive behavioral therapy for insomnia (CBT-I). Outcomes measures were the Menopause-specific Quality of Life scale and its subscales.

RESULTS

Significant improvements in total Menopause-specific Quality of Life from baseline were observed with estradiol, escitalopram, CBT-I, and yoga, with mean decreases of 0.3 to 0.5 points relative to control. The largest improvement in the vasomotor subscale was observed with estradiol (-1.2 points), with more modest but significant effects seen with escitalopram, yoga, and CBT-I. Significant improvements in the psychosocial subscale were observed for escitalopram, venlafaxine, and CBT-I. For the physical subscale, the greatest improvement was observed for CBT-I and exercise, whereas for the sexual subscale, the greatest improvement was observed for CBT-I, with yoga and estradiol demonstrating smaller effects.

CONCLUSIONS

These results suggest that for menopause-related QOL, women have a variety of treatment strategies to choose from and can select an approach based on most bothersome symptoms and individual preferences.

Menopausal Hormone Therapy and Suicide in a National Sample of Midlife and Older Women Veterans

BACKGROUND

Among midlife and older women, menopause symptoms and menopausal hormone therapy have been linked to mental health disorders and other comorbidities related to suicide. However, the role of hormone therapy as a prognostic factor of suicide risk is largely unknown.

OBJECTIVES

To examine associations between menopausal hormone therapy, suicide attempts, and suicide among midlife and older women Veterans.

RESEARCH DESIGN

In this longitudinal analysis of national Veterans Health Administration data from women Veterans aged 50 years and above, we used Fine-Gray proportional hazards models to examine associations between menopausal hormone therapy (prescribed in 2012-2013) and incident suicide attempts and suicide (index date-2016).

MEASURES

Menopausal hormone therapy and psychoactive medications from pharmacy records; suicide attempts and suicide from national suicide data repositories; demographic variables, medical and psychiatric diagnoses, and substance use disorders from electronic medical record data and International Classification Diagnoses-9-CM codes.

RESULTS

In this national sample of 291,709 women Veterans (mean age 60.47, SD 9.81), 6% were prescribed menopausal hormone therapy at baseline. Over an average of 4.5 years, 2673 had an incident suicide attempt (93%) or death by suicide (7%). Adjusting for age, race, and medical diagnoses, menopausal hormone therapy was associated with increased risk of suicide attempt (hazard ratio 1.41; 95% confidence interval, 1.22-1.64) and over 2-fold increased risk of death by suicide (hazard ratio 2.47; 95% confidence interval, 1.58-3.87). Associations with death by suicide remained significant after accounting for psychiatric comorbidity and psychoactive medications.

CONCLUSIONS

Menopausal hormone therapy may be an important indicator of suicide risk among midlife and older women.

Hormone replacement therapy - where are we now?

Hormone replacement therapy (HRT) was the standard of care for menopause management until 2002, when perceptions changed following release of the initial results from the Women's Health Initiative (WHI) trial. Fears of breast cancer and heart attacks engendered by that report were not supported by the data, especially for recently menopausal women. Clinically, HRT is usually initiated near menopause. The WHI tested something different - the effects of HRT started a decade or more after menopause. As it turned out, age at starting HRT is critical in determining benefit/risk. HRT use plummeted following the WHI in 2002 and has remained low, prompting strong interest in alternative treatments. None provide the range of benefits across multiple organ systems offered by estrogen. Most have concerning adverse effects in their own right. HRT can provide effective relief for a wide range of health conditions, potentially avoiding the need for multiple treatments for separate problems. Unfortunately, among many women and clinicians, the perception of HRT benefit/risk is distorted, and its use avoided, leading to unnecessary distress. Following the WHI, many clinicians have not received adequate training to feel comfortable prescribing HRT. When initiated within 10 years of menopause, HRT reduces all-cause mortality and risks of coronary disease, osteoporosis, and dementias.

Symptomatology and quality of life between two populations of climacteric women

PURPOSE

The aim of this study is to compare climacteric symptomatology and sociodemographic conditions and their effect on quality of life in two populations: Monterrey (Mexico) and Madrid (Spain).

METHODS

469 women from Monterrey (mean age 50.5 + 4.3 years) and 452 (mean age 51.7 + 3.7 years) from Madrid participated in the study. Descriptive analyses of sociodemographic and clinics characteristics of the sample were performed. A cross-sectional design and a regression analysis were performed to establish the sociodemographic and clinical variables that would be used as predictors of quality of life. Data was collected using the Menopause-Specific Quality of Life, MENQOL, the Menopause Rating Scale (MRS), the Hospital Anxiety and Depression Scale (HADS), the Quality of Life Scale for Women Aged From 45 to 64 (QLS), and a sociodemographic and clinical interview designed ad hoc.

RESULTS

Approximately 60% of both Spanish and Mexican women present symptoms during climacteric that impairs their quality of life. Spanish women suffer more intense symptoms and for a longer period of time than Mexican women, with the exception of anxiety. Mexican women report better quality of life than Spanish women and it is moderated by educational, socioeconomical, and marital status. Women's knowledge about menopause is also related to a better quality of life.

CONCLUSIONS

Our study confirms the differences in climacteric symptomatology between populations and the impact of educational level and knowledge about menopause as predictors of a better quality of life in climacteric women.

Hormone therapy for first-line management of menopausal symptoms: Practical recommendations

Hormone therapy use has undergone dramatic changes over the past 20 years. Widespread use of hormone therapy in the 1980s and 1990s came to an abrupt halt in the early 2000s after initial findings of the Women’s Health Initiative trial were published and the study was terminated. Since then, much has been learned about the characteristics of women most likely to benefit from hormone therapy. There is general agreement that women younger than 60 years or who initiate hormone therapy within 10 years of menopause onset gain short-term benefit in terms of symptomatic relief and long-term benefit in terms of protection from chronic diseases that affect postmenopausal women. Despite accumulating evidence in support of hormone therapy for symptomatic menopausal women, the slow response by the medical community has led to a ‘large and unnecessary burden of suffering’ by women worldwide. Greater efforts are clearly needed to educate physicians and medical students about the pathophysiology of menopause and the role of hormone therapy in supporting women through the transition. This article provides a brief historical perspective of events that led to the backlash against hormone therapy, explores the current position of guideline groups, and provides practical recommendations to guide first-line management of symptomatic menopausal women.

Oral 17β-estradiol/progesterone (TX-001HR) and quality of life in postmenopausal women with vasomotor symptoms

Objective:

The aim of the study was to describe the effects of TX-001HR (17β-estradiol [E2] and natural progesterone [P4] in a single oral capsule) on menopause-specific quality of life in women with moderate to severe vasomotor symptoms (VMS).

Methods:

The REPLENISH study (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial which evaluated four E2/P4 doses in postmenopausal women with VMS and a uterus. Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were included in a VMS substudy. Participants self-administered the Menopause-Specific Quality of Life (MENQOL) questionnaire. Baseline changes in MENQOL overall and domains were determined as well as correlations between changes in MENQOL scores and VMS frequency or severity.

Results:

In the VMS substudy, women treated with E2/P4 had significantly greater improvements from baseline in their MENQOL overall score at week 12, and months 6 and 12, compared with placebo (all, P < 0.05, except the lowest E2/P4 dose at months 6 and 12). Improvements from baseline for the MENQOL vasomotor domain score were significantly greater with TX-001HR doses versus placebo at all time points (all, P < 0.01). Changes in MENQOL vasomotor scores moderately correlated with changes in VMS frequency (r = 0.56, P < 0.0001) and severity (r = 0.55, P < 0.0001).

Conclusion:

In the REPLENISH trial, women with moderate to severe VMS treated with most E2/P4 doses reported significant improvements in quality of life from baseline to 12 weeks compared with placebo, which were maintained up to 12 months. TX-001HR, if approved, may provide the first oral hormone therapy formulation in a single capsule containing E2 and P4 for the treatment of VMS in postmenopausal women with a uterus.

Association of menopause and type 2 diabetes mellitus

OBJECTIVE

Limited information is available on the direct effect of menopause and risk of type 2 diabetes mellitus (T2DM) among women with different metabolic types. We aimed to investigate whether menopause is a direct risk factor for T2DM.

METHODS

In this population-based cross-sectional study, women were recruited from a rural area of China from July to August 2013 and July to August 2014. Multivariate logistic regression analysis yielded adjusted odds ratios (ORs) and 95% CIs. Mediation analysis was performed to examine the contribution of age to menopause status-related T2DM.

RESULTS

We included 8,191 women (median age 56, interquartile range 47-65). The prevalence of T2DM was 13.22%. Risk of T2DM was increased with postmenopause versus premenopause status after adjustment (adjusted OR [aOR] = 1.90, 95% CI = 1.51-2.37), with the strongest association between postmenopause status and T2DM among women with body mass index (BMI) <24.0 kg/m (aOR, 3.25; 95% CI, 1.98-5.32). Risk of T2DM was increased with postmenopause status interacting with BMI, hypertension, triglycerides level, and waist circumference. On mediation analysis, age partially mediated the menopause status-T2DM association (indirect effect: OR = 1.27, 95% CI = 1.13-1.46; direct effect: OR = 1.88, 95% CI = 1.49-2.36).

CONCLUSIONS

The prevalence of T2DM is high among women, and postmenopause status might be a stable and significant risk factor for T2DM; especially, postmenopausal women with normal weight should not be ignored in addressing the risk.

Menopause hormone therapy: latest developments and clinical practice

Menopause hormone therapy (MHT) is the most efficient treatment for symptoms of acute climacteric syndrome and for efficient prevention of long-term estrogen deficiency. Vaginal administration of low doses of estrogen is a therapy of choice for treatment and prevention of urogenital atrophy and its consequences. Systemic treatment may include estrogen, but an equally efficient alternative is tibolone. Nonhormonal therapy relies on phytoestrogens, black cohosh extract, and serotonin reuptake inhibitors.

Choice of progestogen for endometrial protection in combination with transdermal estradiol in menopausal women

Transdermal estradiol (TE) application (using gels, patches or a novel spray) is now a preferred route of hormone therapy (HT) in menopausal women, because various risks such as venous thromboembolism, stroke and unwanted hepatic effects can be reduced compared with oral HT. However, in the presence of an intact uterus, concurrent administration of progestogen is needed for endometrial protection. Due to the variety of progestogens available and differences in their clinical effects, the selection of the most appropriate substance and dosing for individual combination therapy can be difficult. This is especially true for TE gels and the novel spray because no fixed combination products are commercially available, meaning all progestogens must be added separately, and even for patches only two transdermal synthetic progestogens are available. The aim of this review was to summarize data on the endometrial effects of the different progestogens and to provide practical recommendations for the choice of progestogen (type and dosing), with a focus on endometrial protection when using TE, especially when using the novel estradiol (E2) spray.

The 2017 hormone therapy position statement of The North American Menopause Society

The 2017 Hormone Therapy Position Statement of The North American Menopause Society (NAMS) updates the 2012 Hormone Therapy Position Statement of The North American Menopause Society and identifies future research needs. An Advisory Panel of clinicians and researchers expert in the field of women's health and menopause was recruited by NAMS to review the 2012 Position Statement, evaluate new literature, assess the evidence, and reach consensus on recommendations, using the level of evidence to identify the strength of recommendations and the quality of the evidence. The Panel's recommendations were reviewed and approved by the NAMS Board of Trustees.Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause (GSM) and has been shown to prevent bone loss and fracture. The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing or discontinuing HT.For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is most favorable for treatment of bothersome VMS and for those at elevated risk for bone loss or fracture. For women who initiate HT more than 10 or 20 years from menopause onset or are aged 60 years or older, the benefit-risk ratio appears less favorable because of the greater absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. Longer durations of therapy should be for documented indications such as persistent VMS or bone loss, with shared decision making and periodic reevaluation. For bothersome GSM symptoms not relieved with over-the-counter therapies and without indications for use of systemic HT, low-dose vaginal estrogen therapy or other therapies are recommended.This NAMS position statement has been endorsed by Academy of Women's Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women's Association, American Society for Reproductive Medicine, Asociación Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d'études de la ménopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women's Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women's Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women's Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Società Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.

The Influence of Cigarette Smoke Exposure on the Copper Concentration in the Serum Depending on the Use of Menopausal Hormone Therapy

This study evaluated the effect of menopausal hormone therapy (MHT) on serum concentration of copper in postmenopausal women depending on passive or active exposure to tobacco smoke or lack thereof. The study included healthy postmenopausal women aged 42–69 years, who used (n = 76) or did not use (n = 76) MHT. Salivary cotinine and serum copper concentrations were determined in all the study subjects. Salivary cotinine exceeded 14 ng/ml in 14 women from the MHT group (18.5%) and in 16 controls (21.1%). Up to 41 (27%) study subjects had serum copper above the upper normal limit (1.17 mg/l). No correlation was found between salivary cotinine and serum copper in women with cotinine concentrations <14 ng/ml, and these two parameters correlated weakly in subjects with cotinine >14 ng/ml. Salivary concentration of cotinine increased with serum copper level in the MHT group, but not in the controls; smokers using MHT presented with significantly higher serum copper than nonsmokers. These findings imply that MHT does not affect serum concentration of copper in women who are not exposed to tobacco smoke. However, MHT seems to contribute to unfavorable increase in serum copper in passive and active smokers.

A model of care for healthy menopause and ageing: EMAS position statement

Worldwide, the number of menopausal women is increasing. They present with complex medical issues that lie beyond the traditional scope of gynaecologists and general practitioners (GPs). The European Menopause and Andropause Society (EMAS) therefore provides a holistic model of care for healthy menopause (HM). The HM healthcare model's core consists of a lead clinician, specialist nurse(s) and the woman herself, supported by an interdisciplinary network of medical experts and providers of alternative/complementary medicine. As HM specialist teams are scarce in Europe, they are also responsible for structuring and optimizing processes in primary care (general gynaecologists and GPs) and secondary care (HM specialists). Activities for accreditation of the subspecialty Women's Health are encouraged.

Validation and reliability of the Turkish Utian Quality-of-Life Scale in postmenopausal women

OBJECTIVE

There are a limited number of menopause-specific quality-of-life scales for the Turkish population. This study was conducted to evaluate the validity and reliability of the Turkish Utian Quality-of-Life Scale in postmenopausal women.

METHODS

The study group was comprised of 250 postmenopausal women who applied to a training and research hospital's menopause clinic in Turkey. A survey form and the Turkish Utian quality-of-Life Scale were used to collect data, and the Turkish version of Short Form-36 was used to evaluate reliability with an equivalent form. Language-validity, content-validity, and construct-validity methods were used to assess the validity of the scale, and Cronbach's α coefficient calculation and the equivalent-form reliability methods were used to assess the reliability of the scale.

RESULTS

The Turkish Utian Quality-of-Life Scale was determined to be a valid and reliable instrument for measuring the quality of life of postmenopausal women. Confirmatory factor analysis demonstrates that the instrument fits well with 23 items and a four-factor model. The Cronbach's α coefficient for the quality-of-life domains were as follows: 0.88 overall, 0.79 health, 0.78 emotional, 0.76 sexual, and 0.75 occupational. Reliability of the instrument was confirmed through significant correlations between scores on the Turkish version of the Utian Quality-of-Life Scale and the Turkish version of the Short Form-36 (r = 0.745, P < 0.001).

CONCLUSIONS

This research emphasizes that the Turkish Utian Quality-of-Life Scale is reliable and valid in postmenopausal women-it is a useful instrument for measuring quality of life during menopause.

Menopause

Menopause is an inevitable component of ageing and encompasses the loss of ovarian reproductive function, either occurring spontaneously or secondary to other conditions. It is not yet possible to accurately predict the onset of menopause, especially early menopause, to give women improved control of their fertility. The decline in ovarian oestrogen production at menopause can cause physical symptoms that may be debilitating, including hot flushes and night sweats, urogenital atrophy, sexual dysfunction, mood changes, bone loss, and metabolic changes that predispose to cardiovascular disease and diabetes. The individual experience of the menopause transition varies widely. Important influential factors include the age at which menopause occurs, personal health and wellbeing, and each woman's environment and culture. Management options range from lifestyle assessment and intervention through to hormonal and non-hormonal pharmacotherapy, each of which has specific benefits and risks. Decisions about therapy for perimenopausal and postmenopausal women depend on symptomatology, health status, immediate and long-term health risks, personal life expectations, and the availability and cost of therapies. More effective and safe therapies for the management of menopausal symptoms need to be developed, particularly for women who have absolute contraindications to hormone therapy. For an illustrated summary of this Primer, visit: http://go.nature.com/BjvJVX.

Recommendations for hormone therapy in hysterectomized women: importance of new data in clinical management

Women with a prior hysterectomy with and without oophorectomy represent special cohorts among those who require menopausal hormone therapy (HT), as a progestogen is not required for endometrial protection. This is relevant in light of recent research demonstrating superiority of estrogen therapy alone compared with estrogen plus a progestogen with respect to breast cancer risk and perhaps even cardiovascular protection. No longer is it appropriate to lump all HT regimens together when advising patients. Unfortunately, there is a general reluctance in the healthcare community to prescribe HT even a decade after publication of the results of the Women's Health Initiative trial. However, with subsequent research showing a favorable benefit/risk balance of short-term estrogen therapy in symptomatic, recently menopausal women, especially those who have undergone hysterectomy with oophorectomy, the need for educating patients and providers on the matter cannot be overemphasized.

To exercise, or, not to exercise, during menopause and beyond

Menopausal symptoms in women can be severe and disruptive to overall quality of life. Hormone replacement therapy, is known to be effective in ameliorating symptoms, however, reporting of side effects has resulted in alternative treatment options. Exercise has been assessed as an alternative treatment option for alleviating menopausal symptoms, including, psychological, vasomotor, somatic and sexual symptoms. Here we report the effects of physical activity and exercise on menopause symptoms in menopausal women.