Surviving the last 25 years at work – The benefits of following the evidence………with a little persistence!

We have both spent over 25 years working in the field of menopause and like so many of our peers, and many of you, this has been a journey in this area of medicine that has needed persistence combined with resilience, all very much in the interests of women, their experiences and needs during the menopause.

Prior to the publication of the Women’s Health Initiative (WHI) study in 2002 our experience of looking after women during this phase of their life was very much a positive experience – seemingly solid evidence that HRT was effective in the treatment of symptoms and increasing evidence of efficacy in longer term conditions such as osteoporosis, urogenital changes and early evidence of benefit to the cardiovascular system.

With huge media attention to the risks of HRT highlighted in the WHI study, things then changed dramatically, not just our professional opinions of hormone therapy, but the regulatory position, such that doctors and care professionals around the world felt that they had to change their approach to HRT prescribing. Many women also stopped their HRT for numerous reasons, although results of an online survey in 2011 of 1100 women who had stopped HRT, showed that 56.4% were influenced by the media and 46.5% would not have stopped HRT given the subsequent understanding of risk. ¹

The decade of suffering that ensued is well described, but our feeling is that this suffering could continue beyond a second decade as our recovery from 2002 has not progressed in the way that we feel it perhaps should have.

For those of us that have remained interested in the management of the menopause and the place of HRT for these two decades we have needed to live and work in a profoundly evidence-based fashion, using high quality communication skills to explain risks and benefits of interventions that may help women in the short, medium and long term. Women with major comorbidities such as cardiovascular, thromboembolic, autoimmune diseases or previous cancers often found it so hard to get a referral to a specialist menopause clinic.

Thankfully those working in the world of academia and research continued their work in original studies, large population based studies, systematic reviews and importantly reanalyses and reinterpretation of the most influential studies. It was much of this work that contributed to the hugely successful 2015 UK NICE guidance for the management of the menopause, a real landmark moment for all of us – women, carers and researchers alike.

For many of us devoting our career to such an important time in the life of women it was a real moment that showed our persistence had really paid off.

Why do we feel a little concerned about the future? Sadly the signs are there for us to see but may not be evident to those running effective menopause services or those who have access to menopause treatment through a primary care service that is able to offer the correct advice. The current system remains challenging for women and the responsiveness of the care they get really does depend on where they live and the locally available services.

The increase in awareness through celebrity endorsement, government activity and expansion of private sector clinics whilst welcome has placed the NHS under extreme pressure. Many primary care environments do not necessarily have the required expertise, waiting lists to be seen in secondary care and specialist clinics often stretch beyond a year in some areas and the impact of bleeding irregularities with both licensed and non-licensed HRT regimes is being felt in the postmenopausal bleeding clinics (PMB) around the country.

The speed with which these changes has happened is greater than the speed at which services can be upscaled. The impact on PMB services is considerable and to help manage this demand the BMS are working with partners to produce guidance to assist. However, the greatest need is the training of management of the menopause for those in the primary care, and of course this takes time to ensure learners enter clinical practice with the right skills to deliver safe effective care.

Another area that has failed to keep up with demand is the availability of some HRT preparations. This has understandably created significant stress amongst patients and carers. The work of the BMS to shine a light on the problem, advocate for women, and keep people informed and up to date has been invaluable but still shortages happen and it should also be recognised that helping women stay stable and safe on changing treatments takes up additional clinician time that again puts more pressure on the system.

We have a new draft NICE guideline and many of us have fed back as is expected of us. The hope is that the final version of this is something that will update and facilitate not just the vital issue of shared decision making but will also help the modernisation and expansion of menopause services nationally. The onus of continuing to provide the best possible evidence based menopause care will depend on all of us who work in this area and we should see this as another opportunity to grasp as we all did in 2015.