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Promoting Lifelong Health
British Menopause Society 23rd annual conference

Stratford-upon-Avon
Thursday 23 and Friday 24 May 2013

Who should attend?
Academics and students; Dieticians; GPs; Gynaecologists; Nutritionists; Pharmacists; Physiotherapists; Practice Nurses; Specialist Nurses and GP & O & G trainees.
Accreditation: 12 hours CME accredited by the Faculty of Sexual and Reproductive Healthcare (FSRH).

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LATEST NEWS
Withdrawal of testosterone implants
20 December 2012

Testosterone replacement can have a huge impact on general quality of life as well as the libido of many women in the menopause.

The expected announcement by MSD of the withdrawal of testosterone implants has recently been circulated to health professionals. This is a global profitability decision by the company which follows closely on from the withdrawal of estradiol implants.

Even more disappointingly, this decision followed on closely from the withdrawal of the Intrinsa testosterone patches, leaving no licensed female testosterone replacement preparations available in the UK or abroad.

The BMS and all other menopause societies globally, have already protested the withdrawal of estrogen and testosterone implants, which will disadvantage a significant proportion of menopausal women who have struggled with alternative preparations. Whilst the decision by MSD to withdraw hormone implants was immoral, it was not illegal and cannot be reversed.

It has been possible for most clinics to source estrogen implants from an alternative supplier, Pharmarama in the USA. The BMS are now striving to source alternative testosterone implants and will inform the membership as soon as we have any news.

In the meantime, off license use of testosterone gel can be used as an alternative -Testim and Tesostogel can be used at a dose of 0.5 to 1.0 ml per day such that each tube/sachet lasts for approximately 1 week (a large pea sized blob applied to the lower abdomen) or Tostran gel, 1 pump every 2-3 days. As with any off label prescribing, responsibility lies with the health professional rather than the manufacturer/supplier.

Androgenic side effects are uncommon with these female physiological doses and reversible if they do occur, with dose reduction or cessation.

Livial (tibolone) has an androgenic effect and can also be used as an alternative to implants (though the progestogenic effect is not required or desirable in hysterectomised women).

Further updates will be provided as information becomes available.

Nick Panay BSc MB BS MRCOG MRSRH
Chairman, British Menopause Society.

RECENT NEWS
HRT and cardiovascular prevention
10 October 2012

A Danish study reported this week in the British Medical Journal has concluded that after 10 years of follow-up, women receiving HRT early after menopause had a significantly reduced risk of mortality, heart failure, or myocardial infarction, with no apparent increase in risk of cancer, stroke, or blood clot.

1006 healthy women aged 45 to 58 who were recently menopausal were randomly allocated to receive HRT or placebo. Intervention was stopped after 11 years, but follow-up continued for up to 16 years.

The beneficial effects of taking HRT in this randomized trial, agree with data from observational studies which have consistently indicated a reduced risk of heart disease with the use of HRT. Confusion has arisen over the last decade following publication of results of HERS and WHI trials, which both suggested an increased risk of heart disease with the use of HRT. However, most women in these trials were older than 60 years and more than 10 years postmenopausal when starting HRT as part of the trials. Re-analyses of these and other randomized trials have now shown that heart disease and total mortality are reduced when HRT is initiated in women aged less than 60 years, or within 10 years of the menopause. This new Danish trial reinforces the message of a “window of opportunity” for cardiovascular benefit with HRT, while reassuringly emphasizes the safety of HRT in terms of no significant risks even when used for more than 10 years.

Commenting on behalf of Women’s Health Concern and the British Menopause Society, Dr John Stevenson:

“Its main importance is the absolute safety of HRT with long term use. Because of the young age of the women, the numbers of events are very small, ……but the trends are clear - a reduction in Coronary Heart Disease and in all-cause death, a significant reduction when these endpoints are combined (which was the planned primary endpoint of the study), no increase in stroke, VTE or any cancer, and a non-significant reduction in breast cancer (i.e. no increase). The strength of this study is the long duration of use. The safety concerns generated 10 years ago by biased reporting and mis-interpretation of HRT studies have been steadily assuaged by further analyses and reappraisals of those studies. This latest study totally reinforces this. The mantra “use HRT at the lowest dose for the shortest time” was never evidence-based, and this is now evidence against it. The other mantra that HRT must be stopped on safety grounds after 5 years duration should be blown out of the water!”

Surely now both women and healthcare professionals can again take and prescribe HRT when required for control of menopausal symptoms, or for treatment or prevention of osteoporosis without undue concern about risk and with reassurance about heart benefit when started early.

Reference:
Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomized trial. Schierbeck L L, Rejnmark L, Tofteng C L, et al. BMJ 2012;345:e6409

In the Press:
http://www.bbc.co.uk/news/health-19886932
http://www.dailymail.co.uk/health/article-2215345

KEEPS trial results

Results of the Kronos Early Estrogen Prevention Study (KEEPS), presented at the North American Menopause Society annual conference last week, has shown that HRT started soon after the menopause appears safe and relieves many menopausal symptoms, as well as improving mood and cardiovascular risk markers.

KEEPS was a 4 year randomized, placebo controlled trial of low dose oral or estrogen patch and cyclical progesterone in women aged 42 to 58 who were within 3 years after the menopause at randomization.

Many beneficial effects of HRT were found with improvements in hot flushes, night sweats, mood, sexual function and bone density, with no differences in adverse events such as breast cancer, endometrial cancer, myocardial infarction, stroke or blood clot. Regarding cardiovascular effect, some measures showed slight evidence that HRT may be cardioprotective in this age group.

These results should provide reassurance for the many women who are considering taking HRT, or are already taking HRT, for control of menopausal symptoms in the early menopausal years, and for the healthcare professionals who may be unsure about prescribing HRT.

Chairman’s Message:
Good news for HRT - now lets go forwards!
Nick Panay 11th October 2012

The new data from the Danish and KEEPS trials reaffirms the belief of many of our members, from their experience of prescribing for many decades, that HRT is not only safe and efficacious but also confers primary prevention benefits to long term users. However, the data from these new studies are only of use if these messages are conveyed effectively to menopausal women and their primary carers.

The merger of BMS with our patient arm Women’s Health Concern will certainly help to get the key messages directly to women, as will informative websites such as Menopause Matters.  However, it is imperative that all health professionals involved in the care of women in the menopause have ready access to correct, contemporary information such as the data from the Danish and KEEPS studies.

The key aim of our ongoing liaison of the BMS with the Royal College of General Practitioners is to optimize training in post reproductive health in primary care. The BMS is also striving, through its recommendations on menopause, to lobby for resources from the secretary of state for health. This will enable every woman approaching the menopause to have the opportunity to engage in a discussion about her general health, HRT and alternatives. The current level of funding and resourcing in primary care is restricting access of women to their GPs and nurses for the purposes of women’s midlife health and in the meantime, menopause and HRT remain taboo subjects.

The Department of Health, through the Medicines and Healthcare products Regulatory Agency (MHRA) should reconsider the information from the new studies as a matter of urgency and revise the stringent guidelines on HRT prescribing i.e. minimum effective dosage for the shortest duration. In particular, HRT should be reinstated as a first line intervention for osteoporosis prevention, as per the recommendations of all the menopause societies and the National Osteoporosis Society. It could even be argued that there are now sufficient data to consider granting HRT a cardiovascular disease prevention indication for women who commence treatment early in the “Window of Opportunity”.

In conclusion, all the aforementioned strategies should be actioned without delay if we are to restore the rational management of the menopause, where HRT is perceived by all prescribers and their women as being a safe and effective tool to manage their symptoms and maintain their long term health.

Nick Panay , BMS Chairman
10th July 2012

The Women’s Health Initiative Study¹ had a profound effect on the use of HRT and therefore, the lives of millions of menopausal women.

It has now become clear that many of the risks in the WHI study occurred because the dose of HRT was too high for an elderly population of women with an average age of 63 years. There has also been critique as to whether the association with breast cancer was actually causal.² It is imperative that these data are not extrapolated to a younger population of women going through the menopause in their late 40s and 50s and certainly not to women who have gone through a premature menopause

Unfortunately, many GPs are still concerned about prescribing HRT, particularly those qualified in the last 10 years since WHI reported. As a result many women are suffering menopause symptoms in silence, anxious about even approaching their GPs to discuss what the options are for optimising their menopause transition.

Information from the International Menopause Society in their 10 year post-WHI anniversary issue of Climacteric³ and the recent solidarity statement by the North American Menopause Society⁴ have highlighted concerns surrounding the premature way in which the WHI data were initially released and the subsequent damage to the lives of many thousands of menopausal women who were denied a safe intervention on spurious grounds.

The recommendations of the British Menopause Society / Women’s Health Concern (BMS/WHC) to the Department of Health are therefore timely. The key recommendation is that adequate resources should be allocated so that all women can have a discussion as to how they can optimise their menopause transition, with particular reference to lifestyle and diet and an opportunity to discuss the pros and cons of complementary therapies and HRT.⁵

Discussions are now taking place between the BMS/WHC and representatives of the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners to optimise the future dissemination of relevant evidence based information on menopause through primary and secondary care, thus helping to restore women’s confidence in proactively managing their menopause.

Downloads

» Press Release (DOC 28Kb)
» HT Solidarity (PDF 102Kb)
» HT Solidarity Statement Press Release (PDF 109Kb)

Key References

1. Writing group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomised controlled trial JAMA 2002; 288(3): 321-33.
2. » Shapiro S , » Farmer RD , » Mueck AO , » Seaman H , » Stevenson JC . Does hormone replacement therapy cause breast cancer? An application of causal principles to three studies: part 2. The Women's Health Initiative: estrogen plus progestogen J Fam Plann Reprod Health Care 2011; 37(3): 165-72.
3. » http://informahealthcare.com/toc/cmt/current accessed 10.07.12
4. » http://www.menopause.org/pr0512whi.pdf accessed 10.07.12
5. British Menopause Society Council. Modernizing the NHS: observations and recommendations from the British Menopause Society. Menopause Int. 2011 Jun; 17(2):41-3.

By Nick Panay, BMS Chairman

Download the commentary (DOC 32Kb) Updated: 9 Feb 2012

Download the commentary (PDF 59Kb) Updated: 9 Feb 2012

Read more about the 20th BMS annual conference

BMS Statement

Hope for Women - Essential recommendations launched 19 May 2011.

A statement launched from the British Menopause Society Annual Conference brings hope for women with recommendations that should improve the health of women in the postmenopausal years.

» Click here for the full statement (PDF 46Kb)

The Statement was enclosed in an open letter from the chairman and chief executive of the BMS to the Secretary of State for Health.

» Download open letter (PDF 586Kb)

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Members - a new care pathway, abridged and updated from the 5th edition of Management of the Menopause by Professor Margaret Rees, is now available in the Members area.

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Menopause International

available for members »
Menopause International is an international scientific journal that makes a vital contribution to the study and treatment of the menopause and female post reproductive health. To ensure that you and your colleagues have access to this valuable content, please pass the recommendation form to your librarian.

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Management of the Menopause

5th Edition, May 2009
Margaret Rees, John Stevenson, Sally Hope, Serge Rozenberg and Santiago Palacios
* 4th Edition received a Highly Commended award in the Obstetrics and Gynaecology category in the 2006 BMA Book Awards

Purchase this book and more on the Publications Page »

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