The International Menopause Society Press statement:
Decline in breast cancer is not just because of hormone therapy

On week 7 December, 2009, the American Association for Cancer Research issued a press statement entitled 'Decline in breast cancer: not just because of hormone therapy'. This statement was reporting the work of Dr Brian Sprague, of the University of Wisconsin. The full press release can be found at: http://www.aacr.org/home/public--media/aacr-press-releases.aspx?d=1682

The conclusions of this statement were as follows:

• WHI results led to decrease in hormone use.
• Women experienced steep decline in breast cancer.
• Only part of that decline can be attributed to hormone use.

The International Menopause Society issued the following statement:

Dr David Sturdee, President of the International Menopause Society, said: "Dr Sprague's finding that factors other than the decline in hormone replacement therapy (HRT) use are the major contributors to the drop in breast cancer cases is an interesting result. It seems to support what we have been saying for some time - that the effects of HRT on breast cancer have been overstated. We will need to wait until we see the full paper from Dr Sprague before commenting further, but for now we welcome this report as a contribution to a more balanced debate on the issue of how best to treat women going through a difficult menopause."

The International Menopause Society is the main international society representing clinicians who treat the menopause.
It can be contacted via Tom Parkhill, +44 (0)131 208 3008; email This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
See the IMS website at http://www.imsociety.org/.

Content Updated 12 December 2009

Anti-Mullerian Hormone test alone not reliable.

The so-called “egg-timer” test is now being made more widely available to Australian women. But it is not a reliable marker of fertility if used alone, the Australasian Menopause Society council says.

IVF clinics began promoting the AMH test, which requires a single 5 ml blood sample, in February, 2010.

The test is suggested for women contemplating fertility treatment or women who have had chemotherapy or ovarian surgery.

Young women considering delaying pregnancy may also get a “reality check” by using the test, proponents say.  

Australasian Menopause Society comments:

Anti-Mullerian Hormone (AMH) is produced by the granulosa cells of primary and preantral follicles.  Circulating levels of AMH, combined with other circulating factors and ovarian follicle numbers measured using ultrasound have been used as a measure of ovarian reserve. AMH levels correlate with ovarian follicle MH number.  However, the clinical role for measuring AMH is not yet clear.

AMH alone is not a reliable marker of fertility, time until menopause or ovarian reserve.  AMH may be increased in certain clinical conditions, such as PCOS, but alone is not a reliable marker for PCOS.   Whilst an active area of research, there is currently no well established clinical role for the measurement of AMH in benign gynaecology.

Content updated 23 March 2010

The publication 'Assessment and Management of Cardiovascular Risks in Women - A Short Guide for Menopause Physicians' is now available online in a number of languages.
http://www.imsociety.org/assessment_and_management_of_cardiovascular_risks_in_women.php?SESSID=tf1vsm569mo978t08sda1svmc2

This short guide, which arose from a joint workshop under the auspices of physicians from the European Society of Cardiology (ESC), the European Society of Hypertension (ESH) and the International Menopause Society (IMS), contains essential information to assist menopause physicians in performing a key role in the overall management of women's health

Press statement: International Menopause Society -
Menopause-cardiology workshop calls for action on cardiovascular disease and concludes no increased CVD* risk in taking HRT

A joint menopause-cardiology consensus statement has called for direct action to prevent cardiovascular disease (CVD) in menopausal women. The statement also concludes that there is little evidence of increased CVD risk in taking HRT.

The consensus statement was developed at a Workshop** between menopause specialists and cardiologists organised by the International Menopause Society. The Task Force on Gender of the European Society of Cardiology also participated in the Workshop. The statement was published in the peer-reviewed journal Climacteric in October 2009. The main messages of the Workshop are:

1. Women and their doctors are ignoring the cardiovascular dangers facing women going through and after the menopause. Awareness of the dangers needs to be raised; CVD is the number-one killer of women in the Western world and women should be assessed for CVD and the risk factors for CVD on visits to their gynaecologist.

2. The effects of hormone replacement therapy (HRT) on CVD are favourable, although these depend on the woman's age and medical background. There is a trend that HRT is cardioprotective in younger women. In older women, there is a trend to an increase in CVD risk, although this effect is not statistically significant. In general, HRT is safe for most younger women (i.e. women going through the menopause or in the early postmenopausal period) for the relief of menopausal symptoms.

3. Women older than 60 years, or those with predisposing risk factors, have a very slightly increased CVD risk and should be more cautious. HRT is also known slightly to increase the risk of venous thromboembolism. Overall, however, these risks are small and shouldn't deter women consulting their clinician about whether HRT is suitable for them. It is important that all women discuss their medical history with their clinician before deciding to take HRT.

Dr David Sturdee, Joint Chair of the Workshop and President of the IMS, said:

"This is an important statement, given the concern that was expressed over cardiovascular disease risk when the WHI study was halted in 2002.

Cardiovascular disease is the number-one killer of women in the western world, with around half of women dying from heart attacks, embolisms, thrombosis and stroke. Women are rightly aware of the risks of breast cancer but breast cancer kills 1 in 26, yet CVD is invisible to many women. We want to make evaluation of cardiovascular risk at the menopause a standard part of a gynaecological consultation.

It's vitally important that women are checked for cardiovascular risk factors, and that gynaecologists take the opportunity to look at the cardiovascular health of each woman as she approaches and goes through the menopause. Advice on a healthier lifestyle and cardiovascular treatment should be considered alongside any treatment to help women through the menopause."

Professor Peter Collins (Professor of Clinical Cardiology at the UK's National Heart and Lung Institute, Imperial College and Royal Brompton Hospital and Chair of the European Society of Cardiology's Task Force on Gender), who was also a Chair of the Workshop, said:

"As regards HRT, around the time of the menopause, it has a slight beneficial effect on the cardiovascular system. If you take HRT 10 years after the menopause, it appears to have a negative effect on the cardiovascular system, but it is important to note, as the WHI indicated when re-analysing its data***, this negative effect is of marginal significance. The Workshop's message on HRT would be, if you are in reasonable health, aged 50-59 and you take it for relief of menopausal symptoms, then there is little evidence to support that it has any negative cardiovascular effects.

The important thing is to talk over HRT use with your doctor before starting to make sure that it's right for you. For some women, it's not appropriate, but for most women it improves the quality of their lives while going through the menopause."

* i.e. Those related to arterial disease (atherosclerosis).

** The Workshop Ageing, menopause, cardiovascular disease and HRT was held in Pisa, Italy in February 2009. The Workshop was organised by the International Menopause Society, with the participation of the Task Force on Gender of the European Society of Cardiology.

*** Re-analysis of the WHI data, see (1) Rossouw JE, Prentice RL, Manson JE, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA 2007;297:1465-77, and (2) Manson JE, Allison MA, Rossouw JE, et al. Estrogen therapy and coronary-artery calcification. N Engl J Med 2007;356:2591-602

Glossary

Atherosclerosis is a disease in which plaque builds up on the insides of your arteries, reducing the flow of oxygen-rich blood to your organs and other parts of the body. This can lead to serious problems, including heart attack and stroke. Atherosclerosis is the number-one killer of women in the developed world.

Venous thromboembolism Venous thrombosis is a condition in which a blood clot (thrombus) forms in a vein. The most common forms are pulmonary embolism and deep vein thrombosis.

Content Updated 26 November 2009

WHI and beyond: controversies in HRT

Many women have abandoned hormone therapy (HT) following concern over the findings of increased risk of cancers and heart disease in the Women's Health Initiative and Million Women studies.

The AMS provides here links to the original publications plus some later studies which pose important caveats to the WHI findings.

Issues which doctors and women considering HT should consider include:

• Randomised controlled trials provide the highest level evidence, and evidence of association between HT and disease from observational trials does not prove causation.
• Absolute risk, as well as relative risk, should be considered when weighing risks and benefits for individual women.
• Tailoring HT to the individual can maximise its benefits and minimise its risks.
• Re-analysis of the WHI findings on HT and breast cancer show no increase in breast cancer for oestrogen-only therapy and no significant increase with combined therapy in the first seven years of use in women who had previously not taken HT.
• The International Menopause Society states that for women aged 50 to 59 years, HT remains first line treatment for menopausal symptoms.

Introduction 

Hormone implants as replacement therapy for the menopause have been in use for over 40 years. These guidelines are issued to help medical practitioners. They are therefore guidelines rather than rules.

Most practitioners in this field develop their own particular strategies and may have varying views for example on the levels of E2, which they choose for timing repeat implants.

There is a great deal of variability between laboratories in oestradiol assay results. Your local pathologist should inform you about the specificity of their assay.

It is generally better to use the same laboratory for each patient.

Dr Darren Mansfield

MBBS, FRACP, FJFICM, PhD
Director Epworth Sleep Centre

Self reported sleep disturbances are common among peri and post menopausal women. In a British population based study of 1498 women, the odds ratio for self reported sleep disturbance was 3.4 for post menopausal compared to premenopausal women; and 1.5 for peri versus pre menopausal women(1). However, among women presenting to a menopause clinic, where symptoms of menopause are likely to be substantially higher than in the general community of age matched women, the prevalence of self reported disturbed sleep is as high as 77%.

Dr Terry Young

University of Wisconsin-Madison, USA
Used with permission

Aims:   Sleep apnea, a condition of repeated breathing pauses during sleep, is associated with significant morbidity.   Until recently, the occurrence of sleep apnea in women was unknown because it was believed to be a disease of men.   A high prevalence of sleep apnea in middle-aged women has now been established, but >85% of cases remain undiagnosed and serious gaps exist in understanding the unique aspects of sleep apnea in women.   We investigated menopause as a predictor of sleep apnea in a sample of 589 midlife women enrolled in the Wisconsin Sleep Cohort Study.

Professor Lorraine Dennerstein AO MBBS PhD DPM FRANZCP
Professor Dept. Of Psychiatry
Director, Office for Gender and Health
The University of Melbourne

What happens to most women's sexual functioning as they pass through the menopausal transition? Which particular aspects of sexual functioning are affected? Do effects reflect hormonal changes or psychosocial factors such as negative expectations of the menopause? If hormonal factors are involved which hormone is responsible: estradiol or testosterone?

We already know from studies of women attending specialist menopause clinics that sexual problems are amongst the three most common complaints (Sarrel and Whitehead). However women attending such clinics are known to differ from the general  population of mid-aged women in a number of ways which limit  the results of studies of such convenience groups.