Managing Menopause: Are the WHI Results Being Misunderstood?

JoAnn E. Manson, MD, DrPH


March 03, 2016

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Hello. This is Dr JoAnn Manson, professor of medicine at Harvard Medical School and Brigham and Women's Hospital. I would like to talk with you about a prospective piece that I and my colleague, Dr Andrew Kaunitz, have recently published in the New England Journal of Medicine, titled "Menopause Management: Getting Clinical Care Back on Track."[1] We wrote this article to address ongoing confusion about the Women's Health Initiative (WHI) and what it did and did not address. There has been continued misunderstanding about some of the WHI findings.

The WHI was designed to address a very specific question: What is the balance of benefits and risks when menopausal hormone therapy is initiated for the express purpose of trying to prevent chronic disease in postmenopausal women across a broad range of ages, including many women in their 60s and 70s? At the time when the WHI was initiated, it was becoming an increasingly common practice to start hormone therapy in women more than a decade past menopause for the purpose of trying to prevent heart disease, cognitive decline, and many other chronic diseases. The WHI put the brakes on that practice; however, the results have been extrapolated even to women in their 40s and 50s who have severe hot flashes, night sweats, disrupted sleep, and impaired quality of life. Many of these women have had trouble finding clinicians who are willing to prescribe hormone therapy or other treatments for hot flashes and night sweats, and many clinicians do not feel comfortable evaluating menopausal symptoms. To fill this vacuum, many women have turned to untested and unregulated treatments such as custom compounded hormone therapy, for which claims are being made of greater safety and efficacy. Women aren't receiving information about the risks associated with these therapies; for example, there is no package insert.

This is very unfortunate, because most professional societies that address midlife women's health, including the North American Menopause Society (NAMS), the Endocrine Society, the American College of Obstetricians and Gynecologists (ACOG) and others, endorse the use of hormone therapy for management of menopausal symptoms in appropriate candidates—women who don't have contraindications. These professional societies emphasize that the absolute risks associated with hormone therapy are lower in younger women. In women who have symptoms and would get quality-of-life benefits, it is quite likely that the benefits of treatment would outweigh the risks. These organizations have many resources to help clinicians with decision-making about the management of menopausal symptoms. For example, NAMS has many resources, including a free mobile app called MenoPro that provides access to information, materials, and resources to help with the individualization and personalization of decision-making and to promote shared decision-making with the patient about the use of hormonal and nonhormonal treatments.

We need to train and equip the next generation of healthcare providers. Many medical students, trainees, and primary care providers do not feel comfortable managing menopausal symptoms and have not received the necessary training, or are not keeping up on the different options that are available for women. We need to be able to meet the needs of this patient population currently and in the future. Thank you so much for your attention. This is JoAnn Manson.


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