Only 2 menopause guidelines make the grade in quality review

A new online resource on early menopause has been launched to provide up-to-date information for women and tools to assist clinicians in its diagnosis and management.

The project was underpinned by an Australian-led systematic review of available guidelines. The review, published in Maturitas, found menopause guidelines vary in quality with only two of 22 receiving an overall recommendation.

It found guidelines from the UK’s National Institute for Health and Care Excellence (NICE) and the European Society of Human Reproduction and Embryology (ESHRE) topped the list for high quality.

Ten other guidelines, including some from Cancer Australia and the RANZCOG, were assessed as only average quality and requiring some modifications. A further ten guidelines were assessed to be of low quality and therefore not recommended.

Typically, otherwise robust guidelines fell down because they lacked a strategy for implementation and dissemination.

The Monash team then used the three highest scoring guidelines to develop a diagnosis and management algorithm for early menopause /premature ovarian insufficiency (POI). Most general menopause guidelines lacked detailed information on POI management.

Evidence-based algorithm 

They found there was some discrepancy in the recommended FSH cut-off levels for diagnosis but agreed on FSH ≥25 IU/L on two tests at least 4-6 weeks apart in the context of oligo/amenorrhea for at least four months.

Other recommended investigations included karyotype testing, fragile X testing, antibody testing such as thyroid, 21-hydroxylase or adrenocortical antibodies, and pelvic/vaginal ultrasound.

While all three guidelines informing the algorithm suggest menopausal hormone therapy (MHT) until the average age of menopause, there were some inconsistencies regarding the specific regimen.

“This observed variation between guidelines reflects the lack of evidence to guide management of EM/POI and highlights the need for more research,” the review authors said.

Options included in the final algorithm were continuous combined MHT, cyclical combined MHT, combined OCP or levonorgestrel-releasing intrauterine system plus oestradiol if contraception is required, or oestrogen only MHT in the setting of hysterectomy.

Other management strategies included non-hormonal treatments such as SSRIs for vasomotor symptoms where MHT was contraindicated, lifestyle management and referrals to fertility specialists, psychologists and bone loss specialists as necessary.

There was insufficient evidence to recommend herbal therapies or complementary medicines.

Clinical challenges

Associate Professor Amanda Vincent told the limbic that one of the main challenges with early menopause/premature ovarian insufficiency was clinicians even considering the diagnosis in the first place.

“People think of other things but they don’t think it could be early menopause or premature ovarian insufficiency.”

She said apart from the discussions about diagnostic thresholds, FSH was a readily available test and not difficult to do.

“The other problem that we see is that unless a women has a specific contraindication for hormone therapy such as breast cancer, MHT is the best treatment for these women.”

However because of concerns from the Women’s Health Initiative study, which showed an increased risk of breast cancer in post-menopausal women using hormone replacement therapy, she said there was a reluctance to use MHT even in younger women.

“Now the youngest women in that study were 50 years so the problem is that a lot of clinicians are concerned that the risk of HRT in those older women apply to these younger women and they don’t necessarily. You can’t assume there are the same risks.”

“A woman before the age of 50 would normally have some oestrogen in her body so what we are doing in that situation is replacing the oestrogen that her body would otherwise be used to and have if her ovaries were functioning normally.”

“Whereas in a post menopausal woman, her body is designed to have very low levels of oestrogen and so it is not surprising that you start to see some of these risks occur.”

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