by Dragana Skokovic-Sunjic BSc (Pharm)
We see them all the time: they are mothers, daughters, wives of our patients.
Imagine there is a woman standing right there in front of your dispensary. Today she made an unplanned trip to ER with her elderly father, and he was sent home with many medication changes. She just dropped off his new prescription, and she says she is going to wait for it to be ready. She left work early and unexpectedly, there will be many emails to reply to as soon as she gets home. But first, she has to make sure her dad has his medications. And after that, she’ll have to pick up dry cleaning for her daughter, a prom dress was cleaned and pressed. Oh, and don’t forget, Daughter will also need to arrange for pick up after prom and dance is over, likely after midnight – and another important meeting will have to be prepared for work that very next day… Get the gist?
This person, this typical 50-56-year-old woman is the foundation of the modern family, usually 3-generational; she often works full time and holds a fairly responsible position; she is a decision-maker for most of the aspects of her family. And she is presently having a hot flash.
In your pharmacy.
How often is this the case in your pharmacy?
So, what have we done in the past?
Hormone therapy has been used to relieve symptoms of menopause for the past 70 years. We know it can dramatically improve quality of life in women suffering from symptoms, such as hot flashes and night sweats. When we look at the timeline: in 1933 menopause was first described as a deficiency disease; in 1942 we had the advent of oral estrogen tablets. Oral estrogen (sometimes along with oral progestogen) was standard approach leading up to the 1990s that marked the peak in hormone use. In the 1990s and the decades leading up to then, our approach to hormones for menopause could be described as “A round of estrogen for all my friends!” Hormones not only stopped hot flashes, reversed vaginal dryness, and protected bones, they also prevented many chronic diseases and even dementia. It was almost like the fountain of youth. And this continues well into 2002. But 17 years ago, in 2002, women stopped refilling their prescriptions and stopped taking their hormone therapy.
And physicians? They stopped prescribing. But why? What happened?
In 2002, the Women’s Health Initiative or WHI study released their preliminary findings. That study looked into the long-term effects of hormone therapy in older, asymptomatic postmenopausal women. Their first reports did not support protective effect of hormone therapy against heart disease, as described in younger menopausal women. Instead, in the WHI study, hormone therapy was found to increase the risk of blood clotting, stroke, and breast cancer. As a result of these preliminary reports, everything stopped.
The initial findings of this study were actually presented at a press conference, rather than going through standard review process prior to publishing. We were told there was an increased risk of breast cancer and heart attacks and as a result hormone prescription plummeted.
The original WHI findings were misunderstood and misinterpreted as applying to all women who were seeking treatment for menopausal symptoms, when in reality, the trial was designed to assess effects of long-term use of MHT in prevention of chronic disease in older, postmenopausal women. The study results were never intended to be applied to women in their 40s and 50s who were seeking relief from distressing hot flashes and other symptoms that disrupted sleep and impaired quality of life.
After WHI initial news broke, women were offered non-hormonal options and more specifically, lifestyle options, but dressing in layers often doesn’t cut it or simply isn’t possible. Due to socially acceptable norms and more importantly, safety in the workplace, undressing is not always an option.
So, we’ve come a long way, from using MHT for all women, to not using MHT at all, through years of uncertainty and confusion, to today. The controversy from this study rippled for many years. It discouraged an entire generation of healthcare professionals from recommending HT. It also discouraged menopausal women from asking about it.
After WHI, we did not approach patients to discuss hormone therapy, we turned to other options, we dropped menopausal hormone therapy (MHT), and that drop was significant. In the 10 years after the study, without any effective alternatives to replace hormone therapy, the adverse consequences on women’s bone health, among others, was significant. US Public Health data analysis suggests in the 10 years after hormone therapy became controversial, between 18,000-91,000 women may have died prematurely. This was because either their doctors or women themselves feared estrogen, and stopped or never started using it.
A fresh look and deeper analysis of the WHI data paint a different safety picture. The revised data tell us MHT is safe and effective for hot flashes for women starting at less than 60 years of age, and is excellent preventive therapy for osteoporosis. That being said, we as healthcare providers are slow to accept it and recommend it. Many primary care clinicians have had little experience treating menopausal patients. Between 2002 and today we have generations of medical and pharmacy students not being taught about MHT as an option for symptom control.
Doubt and fear are really hard to sway. But it is our job to share what we know, especially when our behaviour shows that we do not have the same doubts and fears about MHT as our patients do. For many of our menopausal women there is a gap from what we know and what we do. A recent study found that only 49% of gynecologists would prescribe HT to their patients, yet 84% of the same doctors would use HT for themselves or prescribe it for their partner, their friends or their family.
It has been shown that women who start MHT within first 10 years of menopause do have reduced risk of heart disease and reduced risk of dying from any cause. The study shows 40% or greater risk reduction with the use of MHT in this population. The numbers we are talking about are not in the least bit small or insignificant.
The bottom line:
Today we can say MHT is safe in the appropriate population and it is the most effective treatment for vasomotor symptoms of menopause and the genito-urinary syndrome of menopause. We also know that women suffer less bone loss and fractures when on HT, they often report improved sex life and overall improvement in QOL.
Is this just my opinion, or are there others out there having these crazy ideas that hormones are good?
More than a decade after the WHI studies were stopped prematurely, many additional analyses and follow-up of original participants have provided new insights into the appropriate use of MHT. This is reflected in the most up to date guideline recommendations both nationally from the SOGC, as well as globally from guidelines from American, British, and international societies and professional organizations. So, it looks like it’s not only my opinion after all….
We as pharmacists can play a role in recognizing and responding to the needs of women we see in our pharmacy. They place their confidence in our knowledge and in our experience.
It’s time to bust the myths about HT and combat the misconceptions that are still circulating. This will be a challenge for years to come, but we need to talk about what we know and the best time to start talking is right now.
Link to guidelines
Dragana Skokovic-Sunjic BSc (Pharm) is a clinical pharmacist with Hamilton Family Health Team and a NAMS Certified Menopause Practitioner. She is also a leader in knowledge mobilization for probiotics in Canada and the United States
Dragana Skokovic-Sunjic will be appearing at Pharmacy U Vancouver. For more information, visit Pharmacy U