Treating menopause — MHT and beyond

• Published in: Nature reviews. Endocrinology 2022-08, Vol.18 (8), p.490-502
• Main Authors: Davis, Susan R., Baber, Rodney J.
• Format: Article
• Language: English
• Subjects: 692/163/2743/2730; 692/700/565; Adult; Age; Bone loss; Breast cancer; Cardiovascular diseases; Complications; Endocrinology; Estrogen Replacement Therapy - adverse effects; Estrogens; Estrogens - therapeutic use; Female; Geographical variations; Hormone Replacement Therapy; Humans; Medicine; Medicine & Public Health; Menopause; Middle Aged; Osteoporosis; Ovaries; Physical activity; Post-menopause; Reproductive status; Review Article; Risk factors
• ISSN: 1759-5029; 1759-5037
• DOI: 10.1038/s41574-022-00685-4

Every woman who lives past midlife will experience menopause, which, by definition, is complete cessation of ovarian function. This process might occur spontaneously (natural menopause) or be iatrogenic (secondary menopause), and can be further classified as ‘early’ if it occurs before the age of 45 years and ‘premature’ if it occurs before the age of 40 years. Globally, the mean age of natural menopause is 48.8 years, with remarkably little geographic variation. A woman’s age at menopause influences health outcomes in later life. Early menopause is associated with a reduced risk of breast cancer, but increased risks of premature osteoporosis, cardiovascular disease and premature death. The cardinal symptoms of menopause, and adverse health sequelae, are due to loss of ovarian oestrogen production. Consequently, menopausal hormone therapy (MHT) that includes oestrogen or an oestrogenic compound ameliorates menopausal symptoms, while preventing menopause-associated bone loss and cardiometabolic changes. Importantly, comprehensive care of postmenopausal women involves lifestyle optimization (attention to nutrition and physical activity, reducing alcohol consumption and not smoking) and treating other established chronic disease risk factors. This Review offers a commentary specifically on the contemporary use of MHT and novel pharmaceutical alternatives to manage menopausal symptoms. Menopause affects roughly half of the global population, yet many affected people do not receive the treatment they need. This Review discusses currently available menopausal hormonal therapies and novel pharmaceutical alternatives to manage menopausal symptoms. Key points Most women experience menopause between the ages of 45 and 55 years, and 75% will experience oestrogen deficiency symptoms. Menopausal hormone therapy (MHT), including tibolone, remains the most effective treatment for menopausal symptoms. MHT considerably lowers the risk of hip, vertebral and other osteoporosis-related fracture in women with normal bone density, osteopenia and osteoporosis; fracture prevention is a primary indication for its use. Urogenital atrophy symptoms are common and should be treated, with several effective hormonal and non-hormonal treatments available. Several novel therapies for the treatment of menopausal symptoms are in development; however, the new non-hormonal therapies are specific for vasomotor symptoms and, unlike oestrogen therapy, will not prevent bone loss or cardiometaboli