Optimizing the menopause transition: Joint position statement by the British Menopause Society, Royal College of Obstetricians and Gynaecologists and Society for Endocrinology on best practice recommendations for the care of women experiencing the menopause

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The British Menopause Society, Royal College of Obstetricians and Gynaecologists and the Society for Endocrinology have produced a joint position statement providing best practice recommendations on the menopause care.1 The statement comes in response to distressing news that some women experiencing the menopause are struggling to access hormone replacement therapy (HRT) treatment due to shortages. As a group of medical organizations, we aim to provide evidence-based guidance to healthcare practitioners who work with women experiencing the menopause so they have the right information and guidance to make informed decisions about their treatment and care. The menopause marks the end of the reproductive life cycle and can affect women in a variety of ways.2 Many women may experience symptoms related to the menopause that can have a detrimental impact on their quality of life and well-being and may also have a significant impact on their personal relationships and work. These can include hot flushes and night sweats, vaginal dryness, a change in mood and memory problems. Whilst not all women going through the menopause will experience menopausal symptoms, the majority will experience such symptoms. It is estimated that menopausal symptoms affect more than 75% of women, with over 25% of women describing severe symptoms. Furthermore, menopausal symptoms may last for a long time with an average duration of 7 years, with a third of women experiencing symptoms beyond 7 years.3 In addition to menopausal symptoms, the menopause can have a detrimental effect on bone health and cardiovascular health, increasing the risk of osteoporosis and cardiovascular disease. Over the last two decades, we have seen a change in the approach to managing and treating the menopause symptoms. There has been plenty of negativity around the menopause and negative aspects of HRT with little reference to the impact the menopause may have on women's quality of life. However, since the publication of the NICE menopause guideline in 2015, there has been a gradual and steady shift to a more holistic approach to managing the menopause.This has resulted in an emphasis on the importance of applying an all-encompassing and individualized approach in managing women going through the menopause transition including the role of HRT.5 The menopause for many women has been shrouded in stigma and taboo; however, in the past couple of years, we have seen an uplift in awareness of the menopause and its symptoms. A focus in the mainstream media has provoked much positive discussion over what treatments are available and what more could be done to support women going through the menopause. Women should be able to seek advice and evidence-based information on how to optimize their menopausal transition and the years beyond. It is important to look not only at the role of HRT when discussing the menopause with women but also to offer advice regarding lifestyle and diet modifications, such as exercise, optimizing weight, stopping smoking, reducing alcohol as well as the advantages and disadvantages of their management options, including HRT and alternative therapies. HRT has been shown to improve symptom control and quality of life. The decision whether to take HRT, and the dose and duration of its use should be made on an individualized basis after discussing the benefits and risks with each patient and no arbitrary limits should be set on age or duration of HRT intake. For most women, HRT has a favourable benefit/risk profile. However, HRT should not be used without a clear indication and should not be used for the sole purpose of disease prevention. The menopause is a life stage and does not represent a deficiency state. Alternative therapies, including cognitive behavioural therapy, can be considered in women who do not wish to take HRT or have contraindications to HRT. Management should also be individualized to the needs of each woman rather than a 'one size fits all' approach. Whilst women are accessing information about the menopause from many resources on the internet and social media, unfortunately, there remains plenty of misinformation, even though this may be well-intended. An example is conflicting information on the risk of dementia with HRT and the role of HRT in the prevention of dementia. Although HRT may help relieve some short-term cognitive symptoms related to the menopause, this should be differentiated from dementia prevention. HRT should not be initiated for the purpose of reducing the risk of dementia in postmenopausal women and the current body of evidence does not support this. In addition, whilst testosterone replacement may offer benefits to women with low sexual desire, there is a lack of evidence to support testosterone supplementation for the purpose of improving cognitive function, musculoskeletal health, bone density or fracture prevention. Testosterone supplementations should therefore not be offered for these indications. Furthermore, advice given to women with a history of breast cancer should be in line with national and international guidance on this matter. HRT in women with a history of breast cancer, regardless of receptor status, should be seen as an exception as the risks are different to those for women who do not have breast cancer. A history of breast cancer should be considered a contraindication to systemic HRT. However, in exceptional cases, HRT may be offered to women with breast cancer experiencing severe menopausal symptoms if lifestyle modifications and nonhormonal treatment options are not effective. HRT prescribing in women with breast cancer should only be considered after a discussion with the woman, her menopause specialist and her breast oncology team. In summary, the menopause is a major life event that can affect women in different ways. There should be an individualized approach in assessing women going through the menopause. It is important women are made aware that help and support is available to them, and it remains essential that women have access to accurate information to be able to seek appropriate advice on how to manage their menopause. Channa N Jayasena has received an NIHR Post-doctoral Fellowship and an investigator led grant fromLogixx Pharma ltd. Edward Morris is a Trustee of RCOG; and British Menopause Society and receives funded Research for Gedeon Richter and Chugai Pharma. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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