Cost-effectiveness of hormone replacement therapy for menopausal symptoms in the UK

Role of menopausal hormone therapy in the prevention of postmenopausal osteoporosis

The use of menopausal hormone therapy (MHT) has declined due to concerns about its potential side effects. However, its pivotal role in managing postmenopausal osteoporosis is gaining increased recognition. In this article, we explore how MHT assists postmenopausal women in maintaining bone health and preventing fractures. Recent research indicates that MHT significantly reduces the risk of fractures in women. This benefit is evident regardless of a woman's bone mineral density or their use of progestogens. However, there is limited evidence suggesting that the skeletal benefits continue once the treatment is discontinued. Possible complications of MHT include heart attacks, clots, strokes, dementia, and breast cancer. The most suitable candidates for MHT are women who have recently entered menopause, are experiencing menopausal symptoms, and are below 60 years of age with a minimal baseline risk of adverse events. The treatment is available to those who meet these criteria. For women undergoing premature menopause, MHT can be considered as a means to protect bone health, especially if initiated before menopause or if accelerated bone loss is documented soon after menopause. Such decisions should be made after evaluating individual risk factors and benefits.

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.

Hormone therapy for postmenopausal osteoporosis management

Menopausal hormone therapy (MHT) has been used for prevention and treatment of postmenopausal osteoporosis for several decades. However, public concerns were raised over the safety of MHT after the initial report was published in 2002 by the Women's Health Initiative. We conducted a historical review on this subject, primarily focusing on level I evidence from randomized controlled trials, systematic reviews and meta-analyses, and summarized high-quality evidence on the efficacy and safety of MHT in management of postmenopausal osteoporosis. Clinical issues were also discussed on MHT initiation, identification of treatment candidates and treatment duration, as well as discontinuation of MHT.

Is there a role for menopausal hormone therapy in the management of postmenopausal osteoporosis?

We provide an evidence base and guidance for the use of menopausal hormone therapy (MHT) for the maintenance of skeletal health and prevention of future fractures in recently menopausal women. Despite controversy over associated side effects, which has limited its use in recent decades, the potential role for MHT soon after menopause in the management of postmenopausal osteoporosis is increasingly recognized. We present a narrative review of the benefits versus risks of using MHT in the management of postmenopausal osteoporosis. Current literature suggests robust anti-fracture efficacy of MHT in patients unselected for low BMD, regardless of concomitant use with progestogens, but with limited evidence of persisting skeletal benefits following cessation of therapy. Side effects include cardiovascular events, thromboembolic disease, stroke and breast cancer, but the benefit-risk profile differs according to the use of opposed versus unopposed oestrogens, type of oestrogen/progestogen, dose and route of delivery and, for cardiovascular events, timing of MHT use. Overall, the benefit-risk profile supports MHT treatment in women who have recently (< 10 years) become menopausal, who have menopausal symptoms and who are less than 60 years old, with a low baseline risk for adverse events. MHT should be considered as an option for the maintenance of skeletal health in women, specifically as an additional benefit in the context of treatment of menopausal symptoms, when commenced at the menopause, or shortly thereafter, in the context of a personalized benefit-risk evaluation.

Prescription of hormone replacement therapy prior to and after the diagnosis of gynecological cancers in German patients

PURPOSE

Little is known about how a gynecological cancer diagnosis affects a gynecologist's decision to prescribe hormone replacement therapy (HRT). Therefore, the goal of this study was to analyze the prevalence of HRT prescription prior to and after the diagnosis of four gynecological cancers in women followed in gynecological practices in Germany.

METHODS

This study included women who were diagnosed with breast, uterine, ovarian, or vulvar cancer in 281 gynecological practices in Germany for the first time between January 2011 and December 2017. The first outcome of the study was the proportion of women with at least one HRT prescription in the year prior to and in the year after cancer diagnosis. The second outcome of the study was the proportion of gynecological practices that issued at least one HRT prescription in the year prior to and in the year after cancer diagnosis.

RESULTS

A total of 7189 women were included in this study. The proportion of women receiving at least one HRT prescription significantly decreased between the year prior to and the year after cancer diagnosis in the breast cancer (16.3% versus 2.3%) and the uterine cancer groups (13.4% versus 5.8%), but not in the ovarian cancer (17.6% versus 15.1%) and the vulvar cancer groups (10.8% versus 13.1%). Similar findings were obtained for the proportion of gynecological practices that issued at least one HRT prescription.

CONCLUSION

HRT prescriptions significantly decreased after the diagnosis of breast and uterine cancers but not after the diagnosis of ovarian and vulvar cancers.

Chinese and Indian women's experience with alternative medications for menopause related symptoms: A qualitative analysis

OBJECTIVE

To explore women's rationalization for using alternative medications, their experience and view on safety of long-term use.

METHODS

Two focus group discussions, involving 5 participants each for Chinese and Indian groups, were conducted separately. Participant's personal information was collected anonymously. The discussion covered 5 areas: determinants for taking medications; reason for choosing alternative medications rather than hormone replacement therapy (HRT); how these medications help them; their view on cost-effectiveness and concerns over long-term use. The discussions were audio-taped, transcribed and analyzed.

RESULTS

Chinese participants took supplements for controlling symptoms while Indian participants used herbs as a preventive measure during menopause according to their tradition. Women of both groups mentioned that they did not take HRT because of fear of side effects. Chinese group mentioned that medications remarkably improved their symptoms whereas Indian participants appreciated their herbals more for improvement in general wellbeing than for specific symptoms. All members agreed that using alternative medication was cost-effective. Both Chinese and Indian participants were quite confident in saying that long-term use will not be associated with any side effects. However, Indian group emphasized that proper preparation of herbal compound using different types of leaves, is essential in order to avoid untoward effects.

CONCLUSIONS

Chinese and Indian women used alternative medicine in prevention and treatment of menopause-related problems even as they were avoiding HRT because of the fear of side effects. They believed that their supplements were effective, safe and cost-beneficial even with long-term use.

Menopausal hormone therapy: a systematic review of cost-effectiveness evaluations

BACKGROUND

Several evaluations of the cost-effectiveness (CE) of menopausal hormone therapy (MHT) have been reported. The aim of this study was to systematically and critically review economic evaluations of MHT since 2002, after the Women's Health Initiative (WHI) trial results on MHT were published.

METHODS

The inclusion criteria for the review were: CE analyses of MHT versus no treatment, published from 2002-2016, in healthy women, which included both symptom relief outcomes and a range of longer term health outcomes (breast cancer, coronary heart disease, stroke, fractures and colorectal cancer). Included economic models had outcomes expressed in cost per quality-adjusted life year or cost per life year saved. MEDLINE, EMBASE, Evidence-Based Medicine Reviews databases and the Cost-Effectiveness Analysis Registry were searched. CE evaluations were assessed in regard to (i) reporting standards using the CHEERS checklist and Drummond checklist; (ii) data sources for the utility of MHT with respect to menopausal symptom relief; (iii) cost derivation; (iv) outcomes considered in the models; and (v) the comprehensiveness of the models with respect to factors related to MHT use that impact long term outcomes, using breast cancer as an example outcome.

RESULTS

Five studies satisfying the inclusion criteria were identified which modelled cohorts of women aged 50 and older who used combination or estrogen-only MHT for 5-15 years. For women 50-60 years of age, all evaluations found MHT to be cost-effective and below the willingness-to-pay threshold of the country for which the analysis was conducted. However, 3 analyses based the quality of life (QOL) benefit for symptom relief on one small primary study. Examination of costing methods identified a need for further clarity in the methodology used to aggregate costs from sources. Using breast cancer as an example outcome, risks as measured in the WHI were used in the majority of evaluations. Apart from the type and duration of MHT use, other effect modifiers for breast cancer outcomes (for example body mass index) were not considered.

CONCLUSIONS

This systematic review identified issues which could impact the outcome of MHT CE analyses and the generalisability of their results. The estimated CE of MHT is driven largely by estimates of QOL improvements associated with symptom relief but data sources on these utility weights are limited. Future analyses should carefully consider data sources and the evidence on the long term risks of MHT use in terms of chronic disease. This review highlights the considerable difficulties in conducting cost-effectiveness analyses in situations where short term benefits of an intervention must be evaluated in the context of long term health outcomes.

Menopause, evolution and changing cultures

The menopause is an isolated event in a much wider process that was probably an evolutionary adaptation essential for survival in the Pliocene. As a reproductive strategy, it is largely vestigial in the 21st century, part of an era that has seen a doubling of the average human longevity compared with that of the past. This process commences as an accelerated decline in female fertility, usually from the fourth decade of life, culminating in a total cessation of reproductive capacity for those surviving. The 20th and 21st century sees a huge increase in the numbers surviving and the duration of that postreproductive life phase extending for decades. This extended period of what is essentially a hormone deficiency state is a recent phenomenon and by no means part of the natural history of the human individual. It is therefore not surprising to see a postmenopausal increase in the incidence of so many disorders above that expected by age alone. Recent reproductive patterns have seen increases in the birth rate and requests for fertility treatments among women in their late 30s and 40s. Many try for pregnancy but are unsuccessful. The genes that permit later reproduction and hence later menopause are therefore being preferentially selected. Slowly over generations we will expect to see the fertility of future 40 year olds increase and the age of menopause to extend much later into our, now, longer lives.