Informed choice: is it achievable?

Abstract

It is clear that an essential aspect of menopause management is the provision of accurate, unbiased information so that women can make informed choices about the management of their own menopause. As outlined in our editorial in a previous issue of Menopause International, provision of this information is currently poor and must improve, yet we live in hope that this will improve and informed choices can be made. But will this ever be possible? There are several issues to be explored that currently throw this idealistic ambition into doubt. Most of the readership of this journal will be aware that with the international decline in enthusiasm for management of the menopause with hormones, there has been a decline generally in the management of the menopause. Think about where you live, was there a menopause clinic that no longer happens, or happens less often? Are you seeing fewer patients with menopausal problems in your clinic? Are more women being unilaterally advised to stop hormone replacement therapy (HRT)? All of these are symptoms of a decline in interest of management of the menopause. This does not mean that there are fewer menopausal women. In fact, the converse is true – it means more women are likely to be suffering. Is this right? With the best will in the world, not all health-care professionals, let alone women, can have access to the most up to date, accurate, unbiased information, which is understandable. Cumming et al. reported that 56.4% of women who stopped HRT following publication of the WHI trial, were influenced by the media and that overall, 46.5% of women who stopped HRT, would not have done so had they been given information of the current understanding of risks of HRT – they did not make an informed choice. Women are frequently exposed to information about the benefits of alternative therapies and yet there continues to be a lack of evidence confirming both effectiveness and safety of such therapies. It is clear that women choosing to purchase alternative therapies are not making fully informed choices. The common symptoms of vaginal atrophy continue to be hugely under-reported and under-treated, with an international survey of 4246 women aged 55–65 reporting that overall 77% believed that women were uncomfortable discussing vaginal atrophy and 42% did not know that local treatment was available. Women continue to suffer from distressing symptoms of urogenital atrophy and do not make informed choices about treatments of this almost inevitable consequence of estrogen deficiency. Over recent years, particularly in the UK, there has been withdrawal of various types of hormone therapy: estrogen nasal spray, preparations of estradiol and dydrogestrone, and most recently estradiol implants, while there has been a dearth in the introduction of new lower dose preparations and combinations. With reduced options available and lack of new options, health-care professionals are less able to make informed choices about the most appropriate treatments for their patients. Part of an article in this issue demonstrates an area of clinical practice where there is a clear need for awareness of the potential iatrogenic menopausal symptomatology that may accompany the management of breast cancer. This need is likely to extrapolate across all areas of disease management that depend upon hypo-estrogenaemia for their clinical effect. While it may not be clinically appropriate to add-back hormones, other approaches to ameliorate symptoms should at least be considered, preferably before the hormone-reducing therapy is commenced. In the UK, we are at an important crossroads in the development of health services. For those of us who care about the management of the menopause we need to recognize that we must show those designing new health-care models that the management of the menopause is not all about HRT prescription, it is key to disease prevention in the postmenopausal years. Should we accept that fully informed choice in menopause management is an ideal, but not achievable in the current climate? It is undesirable to think that we should accept a lesser level of quality of care so, instead, we must endeavour to help guide the National Health Services, health-care professionals, and most importantly women to make as good a choice as possible.