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Menopause research: an opportunity for complementary collaborations
27 December 2017 (online)
Most women in developed countries will be post-menopausal for a third of their lifetime with an estimated 46% of the female population of the UK peri- or post-menopausal by the year 2015.[ 1 ] The menopause transition is a natural process rather than a disease to be ‘cured’ via medical intervention, however, the major focus of menopause research to date has been the use of hormone replacement therapy (HRT) to rectify oestrogen deficiency.[ ∗ ] The advent of HRT in the 1960s and its increasing popularity since, has reduced the perceived need for alternative treatment strategies. Consequently, we have a limited evidence base on which to draw, for those subgroups of women in whom oestrogen replacement therapy is medically contraindicated, not desired, responded to inadequately, or discontinued because of side effects.[ 2 ] This shortcoming is illustrated by the growing recognition of menopausal symptoms as a particular survivorship issue for women with breast cancer, in whom the use of HRT remains controversial.
Over 39,500 women are diagnosed with breast cancer every year in the UK, more than 8000 of whom are pre-menopausal (CRUK, 2003).[ 3 ] Premature menopausal symptoms arise in women with breast cancer for a number of reasons, including: direct therapeutic intervention, eg surgical oophorectomy or ovarian ablation; endocrine therapies, eg Tamoxifen; and ovarian suppression due to cytotoxic chemotherapy regimes. Additionally, women taking HRT pre-diagnosis may be asked to discontinue therapy, causing rebound menopausal symptoms. Recent research has demonstrated that women receiving adjuvant systemic breast cancer treatments have a higher incidence and severity of specific menopausal symptoms (fatigue, hot flushes, night sweats) than women experiencing a natural menopause.[ 4 ] The increasing use of adjuvant therapies in recent decades, together with media coverage of HRT as a universal panacea, has led many women with a breast cancer diagnosis to seek alternative treatments for their menopausal symptoms.[ 5 ]
Various ‘natural’ alternatives to HRT have been promoted commercially and are readily available as health foods or nutritional supplements. Lay interest is mirrored by the professional literature: in a search of MEDLINE from January 1966 to March 2002, Kronenberg and Fugh-Berman[ 6 ] identified 29 randomised, controlled clinical trials of complementary/alternative therapies for menopausal symptoms. Unfortunately, studies published to date lack the potential for meta-analysis or other valid comparison due to diversity in size, populations, designs, interventions, and tools used. Additional difficulties in analysing findings include the natural resolution of menopausal symptoms over time, and a high placebo response rate.[ 7 ]
In this issue of Homeopathy, Thompson and Reilly[ 8 ] make an important contribution to the existing menopause evidence base with their paper ‘The homeopathic approach to the treatment of symptoms of oestrogen withdrawal in the breast cancer patient’. Their suggestion that the homeopathic approach can be integrated into the NHS to offer useful symptomatic control, is timely. The past decade has seen a shift in overall NHS emphasis from buildings and organisations, towards a more patient-focused and holistic philosophy of care. Collaboration across organisational boundaries and professional groups is being championed as the way forward, stimulating creativity and innovation via unprecedented partnerships. The fact that 49% of women referred as potential participants for Thompson and Reilly's study were from the local oncology centre, is a positive indicator for such collaboration, signifying a recognition of complementary professional roles and expertise. This is especially the case since none of the women were refusing conventional cancer treatments, rather they were attempting to obtain a comprehensive and individualised package of care.
Menopause research can be found across a diverse spectrum of professional literature, encompassing health promotion, complementary therapies, cancer care, fertility and sexuality, endocrinology and ageing. Although the body of menopause research has evolved substantially over the last decade, few studies comparing therapeutic interventions are available, and most research attention has focused on acute menopausal symptoms such as hot flushes and night sweats. Still largely untouched are the intermediate and long-term implications of menopause. While Thompson and Reilly conclude that the homeopathic approach appears to be clinically useful in the management of menopausal symptoms in women with breast cancer, they also acknowledge the need for further definitive research. It is interesting to note that fatigue was a significant presenting problem for the women in Thompson and Reilly's study, together with hot flashes, mood disturbances and joint pains. Dodd et al [ 9 ] suggest that while most cancer-care research to date has focused on individual symptoms, health-care professionals need to be aware of symptom ‘clusters’ and their possible synergistic adverse effects on patient morbidity. This is another important area for further exploration.
Mahon and Williams[ 10 ] state that menopause research and management is inconsistent because it is not traditionally the responsibility of any one health-care specialty; however, this critical appraisal may be viewed as a positive opportunity. With randomised trials advocated generally as the ‘gold-standard’ means of resolving research questions, the way forward must lie in collaboration and integration, developing research strategies and subsequent clinical interventions in a way that benefits all. A comprehensive and coherent menopause research strategy would move towards establishing a definitive evidence base for practice in this area, as well as improving supportive care for women in the general population and those women in particularly vulnerable subgroups.
- 1 Varma TR. Sex steroids and cancer in older women. Drugs Aging 1992; 2: 174–195.
- 2 Bachmann GA. Nonhormonal alternatives for the management of early menopause in younger women with breast cancer. J Nat Cancer Inst Monogr 1994; 16: 161–167.
- 3 Cancer Research UK website http://science.cancerresearchuk.org
- 4 McPhail G, Smith L. Acute menopause symptoms during adjuvant systemic treatment for breast cancer: a case—control study. Cancer Nurs 2001; 23: 430–443.
- 5 This P, De La Rochefordiere A, Clough K, Fourquet A, Magdelenat H. Phytoestrogens after breast cancer. Endocrine-Rela Cancer 2001; 8: 129–134.
- 6 Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: a review of randomised, controlled trials. Ann Intern Med 2002; 137: 805–813.
- 7 Davis SR. Phytoestrogen therapy for menopausal symptoms?: There's no good evidence that it's any better than placebo. BMJ 2001; 323: 354–355.
- 8 Thompson EA, Reilly D. The homeopathic approach to the treatment of symptoms of oestrogen withdrawal in the breast cancer patient. A prospective observational study. Homeopathy 2003; 92: 131–134.
- 9 Dodd MJ, Miaskowski C, Paul SM. Symptom clusters and their effect on the functional status of patients with cancer. Oncol Nurs Forum 2001; 28: 465–470.
- 10 Mahon SM, Williams M. Information needs regarding menopause. Results from a survey of women receiving cancer prevention and detection services. Cancer Nurs 2000; 23: 176–185.