“Think Menopause” is at the core of the NHS England and Improvement (NHSEI) initiative to encourage healthcare professionals to consider perimenopause and menopause in all women over 40 years of age, who present with symptoms that could be explained by declining ovarian hormone production as the underlying cause.
Personalisation, personalisation, personalisation…
Last week at the British Menopause Society (BMS) conference there were a wealth of eminent speakers. All shared clinical and research experience and a passion for advancing healthcare provision for women in this age cohort. I was honoured that my abstract was selected for oral presentation in front of the large audience assembled for this conference. My presentation was on the novel approach of modelling female hormones over the menstrual cycle using artificial intelligence techniques, in order to personalise female hormone health. In fact, personalisation of care for women was one of the key messages of this conference.
Although individual women are different, all women share the need for personalised healthcare with tailored individual treatment plans. This approach is particularly relevant when it comes to perimenopause.
Think Perimenopause: the time of uncertainty
At the BMS conference, perimenopause was described as a time in a woman’s life where there is an information gap and uncertainty. Perimenopause is the transition from having regular periods, with associated characteristic fluctuations of female hormones over the menstrual cycle, to the situation of menopause. Menopause is defined as not having periods for 1 year. So, menopause is a retrospective diagnosis. The challenging thing about perimenopause for both women and healthcare professionals is that the typical symptoms of perimenopause are very diverse and could be due to a range of causes and co-morbidities. For example, the onset of irregular periods is one of the key clinical indicators of perimenopause. However, decreasing ovarian responsiveness and reduced hormone production is just one potential cause. With an increasing number of women taking regular exercise and becoming masters athletes, there is the possibility of low energy availability causing hypothalamic down regulation of ovarian hormone production. Conversely, an imbalance of behaviours featuring lack of exercise can lead to energy surplus which can impact hormone networks and regularity of periods. Women are also more likely than men to develop autoimmune conditions, such as that affecting thyroid hormone production, which can impact periods.
This diversity of symptoms, which could be attributable to a multitude of conditions, is why there is uncertainty about whether perimenopause is the underlying cause, particularly in women between 40 and 45 years of age. For this reason, the BMS and National Institute of Clinical Excellence (NICE) guidelines advise that blood testing is useful in distinguishing between potential causes in this age bracket. During my abstract presentation, I argued that this is where modelling female hormones in this age cohort could be particularly helpful as an “anomaly” detector. Essentially identifying in which direction and to what extent the hormone fluctuations of an individual woman deviate away from those hormone patterns found in women with fully functioning hormone networks. As with any clinical measurement, monitoring over time provides the most detailed insights. Furthermore, this approach removes the uncertainty of the perimenopause journey for women and healthcare professionals. Extending the clinical application of modelling a woman’s hormones over her lifespan would help personalise female hormone health and assist women navigate her individual hormone odyssey.
Personalising Menopause: Hormone Replacement Therapy (HRT)
Another area of personalisation of female hormone health that was discussed in depth at the BMS conference was the provision of choice and options when it comes to quality of life and maintaining health during the menopause years. After addressing lifestyle factors, hormone replacement therapy (HRT) improves both quality of life and reduces the risk of health issues in the long term such as cardiovascular disease (CVD) and osteoporosis. CVD is the main cause of death in menopausal women. Titrating the type and dose of HRT for the individual women is very important. Body identical HRT offers many advantages. This is HRT comprised of oestradiol and progesterone which are the identical molecular structure to those hormones that the ovaries produce. This is not to be confused with “bioidentical” HRT which are not advised by BMS as these forms of HRT are neither licensed nor regulated. Personalisation of HRT dose can be achieved with body identical HRT which is both licensed and regulated.
In terms of the route of the oestradiol component of HRT, transdermal options such as via patch or gel offer the advantage over oral forms by not increasing the risk of venous thrombo-embolic events. Furthermore, the transdermal route of oestradiol has a beneficial effect on metabolic health, in particular a favourable lipid profile and reactivity of arterial walls. Gel oestradiol provides the opportunity for small adjustments in dose.
Regarding the progesterone component of HRT, this is essential for all women who have not had a hysterectomy for endometrial protection. Preventing unopposed oestradiol making the endometrial lining very thick. Micronised progesterone is body identical and taken as a soft capsule. “Bioidentical” progesterone cream is not advised by the BMS as there is uncertainty about how well this is absorbed, jeopardising effective endometrial protection. Licensed, regulated body identical micronised progesterone has the advantage over other non-body identical forms of external progesterone in having the lowest androgenic effect and reduced side effect profile. Furthermore, it is the progesterone component of HRT that confers the low, but potential risk of breast cancer. Once again micronised progesterone has the advantage over other contenders with the lowest breast cancer risk. From a practical point of view, micronised progesterone has a mild hypnotic effect which is why it is advised to take in the evening. The advantage of helping sleep is a welcome benefit during menopause when sleep disruption can be problematic.
In conclusion, attending the BMS conference was inspiring. The key messages being to think about the possibility of perimenopause and menopause and to ensure personalisation of female health care to individual women.
Further discussion about the crucial role of hormones in health and practical ways to harness your hormones will be explored in my book on this topic, to be published 28/10/22
“Hormones, Health and Human Potential: A guide to understanding your hormones to optimise your health and performance”
British Menopause Society. Annual Conference 30 June- 1 July 2022. Menopause Care: Maintaining the Momentum https://thebms.org.uk/meeting/bms-31st-annual-scientific-conference/
Hamoda H, Moger S. Looking at HRT in Perspective. Helping women make informed choices. Editorial BMJ June 2022 BMJ 2022;377:o1425 http://dx.doi.org/10.1136/bmj.o1425