Consensus statement on the role of hormone replacement therapy during the menopause in East Asian women
1. Every menopausal woman should be given advice about the menopause and its complications and be given the choice of using hormone replacement therapy (HRT). Whether she chooses to use this treatment will depend on her personal decision regarding the risks and benefits.
2. There are convincing data to show that the administration of HRT relieves vasomotor symptoms, reduces the risk of coronary artery disease and prevents bone loss in postmenopausal women. The administration of HRT may also reduce the risk of Alzheimer’s disease.
3. The main arguments against the use of HRT are the cost and the inconvenience of treatment as well as the possible risk of breast cancer with long-term use.
4. While the ultimate decision should rest with the user, the available data suggest that the benefits of treatment with HRT outweigh the risks.
5. Women who develop symptoms suggestive of oestrogen deficiency during the perimenopausal period should be offered HRT.
6. Menopausal women should be given the option of using HRT once the risks and benefits of treatment have been explained.
7. Provided the woman understands the known risks of treatment and agrees to continue with surveillance whilst using the treatment, administration of HRT can be continued indefinitely.
8. Administration of HRT may also improve the quality of life in menopausal women.
• A regional research programme should be set up to optimize the health and well-being of menopausal East Asian women.
• Research is needed on the role of non-hormonal interventions for the menopause including the use of traditional Chinese medicine and the place of dietary phyto-oestrogens as well as the role of exercise and other life style factors.
Demography of the menopause in East Asian women
The available data suggest a sharp increase in the number of postmenopausal women in the East Asian region in future years. Whilst the number of deaths due to infectious diseases has decreased, non-infective conditions such as cardiovascular disease (CVD), cancer, congenital anomalies, endocrine disorders and accidents are increasing.
There have been major changes in the role of women in East Asia associated with their increase in life expectancy. Quality of life is becoming increasingly important in East Asian women.
• There is a lack of reliable information on ageing and gender differences in East Asia.
• The changing role of East Asian women after the menopause and its socioeconomic impact need further study.
• The incidence of CVD in East Asia is currently lower than that in Western populations, but is increasing.
• The increase in the incidence of CVD in East Asia is related to:
_ an increase in longevity,
– a more atherogenic lipid profile (diet-related),
– an increase in the incidence of diabetes mellitus,
– an increase in the incidence of obesity.
• Available evidence has shown that the administration of HRT to postmenopausal women results in the development of a less atherogenic lipid profile. In particular, concentrations of total cholesterol and low-density lipoprotein cholesterol have been shown to decrease, whilst those of high-density lipoprotein increase. In addition, a small number of studies in East Asian women have shown that the administration of HRT reduces concentrations of lipoprotein (a) and produces an increase in blood flow as shown in Doppler ultrasound studies.
• Administration of HRT with or without a progestogen would be expected to reduce the incidence of CVD in East Asian women.
• Management should also include attention to diet and weight control, physical activity, control of diabetes and hypertension, and reduction in sodium intake and smoking.
• Administration of HRT may also protect against the development of cerebrovascular disease.
• To identify the relative importance of different cardiovascular risk factors in postmenopausal East Asian women.
• To determine the effect of previous and past use of HRT on the incidence of CVD in postmenopausal East Asian women.
• To further examine the effect of HRT on non-lipid risk factors including blood flow, coagulation profile and blood pressure.
• To determine the optimal dose of oestrogen and progestogen to prevent CVD in postmenopausal East Asian women.
• To determine the most appropriate route of administration of HRT in postmenopausal East Asian women.
• To determine the optimal time to commence HRT in order to prevent CVD.
• To perform a feasibility study on whether it is possible to quantify the effects of traditional Chinese medicine on the lipid profile, blood flow and other modifiable CVD risk factors.
• To determine the phyto-oestrogen content of different Asian diets and to examine whether this may be affecting the incidence of CVD.
• To determine the role of HRT in established cases of CVD in East Asian women.
• Available evidence suggests that the frequency and severity of vasomotor symptoms are lower in East Asian than in Caucasian women.
• Administration of oestrogen is effective in controlling vasomotor symptoms in East Asian women.
• Further research is needed to clarify the nature and frequency of vasomotor symptoms in East Asian women.
• Oestrogen deficiency after the menopause results in atrophic changes in the lower genitourinary tract. This may cause atrophic vaginitis or urinary symptoms including frequency, urgency and dysuria.
• Oestrogen replacement therapy alleviates symptoms due to atrophic vaginitis and may improve urinary symptoms, but it is not of proven benefit in the treatment of genuine stress incontinence.
• Short-term local administration of oestrogen in addition to systemic treatment is of benefit for urogenital symptoms.
• The incidence of endometrial cancer is lower in East Asian than in Western women but is projected to increase with a longer life expectancy.
• Women with an intact uterus should always receive combination HRT and not unopposed oestrogen.
• Before commencement of HRT, endometrial biopsy is not necessary if the woman is amenorrhoeic.
• Endometrial biopsy is indicated/recommended in the presence of any abnormal bleeding after the commencement of HRT.
• Transvaginal ultrasonography alone to measure endometrial thickness is considered insufficient to exclude endometrial pathology.
• A progestogen should be prescribed for a minimum of 10 days for the cyclic combined regimen or daily for continuous combined therapy.
• Administration of HRT is not contraindicated in women treated for ovarian carcinoma.
• Administration of HRT is not contraindicated in women treated for cervical carcinoma.
• Currently it is agreed that short-term use of HRT does not increase the risk of developing breast cancer. There are contradictory data on the long-term use of HRT and the risk of breast cancer.
In the presence of risk factors:
• This is not considered a contraindication to start HRT or oestrogen replacement therapy.
• It is advisable to have a pretreatment mammogram and follow-up with mammography and breast examination with or without ultrasonography.
Women with treated breast cancer:
• There are some data to suggest that the administration of HRT does not increase the risk of recurrence in women treated for breast cancer. Having explained the risks/benefits of treatment, HRT may be prescribed.
• There is no known association between the use of HRT and cancer of the vulva or vagina.
• For colorectal cancer, administration of HRT may be protective.
• To establish a cancer registry in East Asian countries.
• To determine the optimal dose and duration of progestogen necessary to prevent endometrial cancer in East Asian women.
• Due to the increase in longevity, the incidence of Alzheimer’s disease is expected to increase.
• Current data suggest that the use of HRT delays the onset and slows the progression of the disease.
• Studies are required to determine the optimal dosage of oestrogen necessary to prevent or treat Alzheimer’s disease.
• Available evidence suggests that the prevalence of osteoporosis in East Asia is increasing.
• The most important aspect of osteoporosis management is prevention of the disease.
• A high peak bone mass before the menopause protects against the development of osteoporosis.
• Administration of HRT prevents postmenopausal bone loss.
• An adequate calcium intake should be encouraged in East Asian women.
• Further community-based studies are required to determine the incidence of osteoporosis in East Asia.
• Further studies are required to determine the minimum dose of oestrogen required to prevent osteoporosis in East Asian women.
• Although fertility rates decline in the perimenopausal years, conception is still possible.
• Pregnancies in these women are often unplanned and are associated with increased risk to both mother and baby.
• Administration of HRT to perimenopausal women does not protect against pregnancy, and appropriate contraception should be given.