Menopause Clinic London

In this very useful editorial, Piral et al. analyse the relationship between menopausal hormone therapy (MHT) and the incidence and prognosis of ovarian cancer (OC), and whether MHT may be prescribed in OC survivors.

The researchers present risk estimates for women with low, moderate and high risk of developing OC and also advise on use of MHT after OC. They go on to discuss the current best evidence for prescribing MHT in cancer survivors and acknowledge the limitations of evidence in certain areas.

MHT probably very slightly increases the risk of developing OC in the general population with the additional risk of OC attributable to using MHT in the range of 1 per 1000 woman-years to 1.5 per 10.000 woman-years. But we still need better evidence stratifying the risk based on type, frequency and dosage of hormones used. For majority of women benefits of MHT would outweigh such risks.

The authors note that women who suffer from endometriosis, and especially those with endometrioma and deep infiltrating endometriosis, may have an increased risk of developing OC, but this is not a contraindication for MHT.

Carriers of genetic causes for OC are offered prophylactic salpingo-oophorectomy and although conflicting data exist, current recommendations suggest treating them with MHT at least until the age of the natural menopause (50).

Prior use of MHT before diagnosis of OC does not worsen the prognosis and may improve it. The authors recommend that MHT may be used in survivors of ovarian germ cell or epithelial OCs, but may not be appropriate for those treated for low-grade serous and granulosa cell s*x cord stromal tumors.

Clinical evidence will keep evolving in this area and further studies and trials will hopefully clarify some of the current uncertainties that persist. Until then, counselling women accurately based on the current data we have will be important.

https://www.maturitas.org/article/S0378-5122(26)00229-X/fulltext

Every piece of evidence is key and adds to our understanding about vaginal oestrogen use for genitourinary syndrome of menopause (GSM) after breast cancer treatment!

Olivia Mitchel and colleagues conducted a retrospective cohort study of 25,874 female patients with breast cancer age 65 years and older diagnosed between 2007 and 2017 using the SEER-Medicare Health Outcomes Survey (MHOS) registry. Patients who used vaginal oestrogen after diagnosis (n = 1,053) were compared with nonusers (n = 24,821). Researchers evaluated associations with overall and cause-specific mortality, adjusting for demographics, comorbidities, and oncologic factors.
Among vaginal oestrogen users, 720 (68.4%) had a duration of use 1 year. Of the 4,263 patients with breast cancer who used tamoxifen, 225 (5.28%) also used vaginal oestrogen. Of the 12,552 patients with breast cancer who used aromatase inhibitors (AIs), 470 (3.74%) also used vaginal oestrogen.
What were the main findings?
Vaginal oestrogen use was associated with decreased overall mortality (adjusted hazard ratio [HR], 0.49; P < .01) and cause-specific mortality (adjusted HR, 0.31; P = .01). For the subgroup of patients receiving adjuvant tamoxifen therapy, vaginal oestrogen use was associated with a decrease in overall mortality that was nonsignificant after adjustment (adjusted HR, 0.86 [95% CI, 0.34 to 2.17]; P = .75). For the subgroup of patients receiving adjuvant therapy with Als, vaginal oestrogen use was associated with a decrease in overall mortality, which was attenuated and lost statistical significance after adjustment (adjusted HR, 0.63 [95% CI, 0.33 to 1.18]; P = .15). What did the researchers conclude?
Vaginal oestrogen use was not associated with worse overall survival or breast cancer–specific survival in this cohort of patients older than 65 years. These findings are reassuring and support the growing evidence that vaginal oestrogen is not associated with adverse survival outcomes and can be considered an option for symptom management in patients with GSM after treatment of breast cancer.

Premature ovarian insufficiency (before 40) or early menopause 40-44) is associated with increased risks of cardiovascular disease, osteoporosis and mortality, but prevalence estimates have been traditionally derived primarily from high-income countries.

Here is a useful study from Raisha Binte Islam and colleagues which aimed to estimate the pooled prevalence and determinants of premature or early menopause among women aged 30–49 in 44 low and middle-income countries (LMICs). The study is one of the largest and most geographically diverse investigations of the prevalence of premature or early menopause in resource-constrained settings.
They pooled the most recent round of Demographic and Health Surveys from 44 countries conducted since 2015, accounting for 716 648 women aged 30–49. What were the results?
The pooled prevalence of premature or early menopause was 7.1% (95% CI 7.0% to 7.2%). Country-level prevalence ranged from 2.3% in Jordan and 2.6% in Gabon to 12% in Ethiopia and 11.5% in Indonesia. Prevalence was consistently higher in rural than urban areas across all regions, with South Asia and East Asia and Pacific showing the highest regional burden. In multivariable analysis, higher education, employment, marriage at age 18 years or older, first birth at age 18 years or older and parity of three or more children were associated with lower odds of early menopause. Conversely, middle wealth index and rural residence were associated with increased odds of premature or early menopause.
The researchers concluded that premature or early menopause, affecting approximately one in every 14 reproductive-age women, is a substantial public health burden concentrated in South Asia, East Asia and Pacific, and sub-Saharan Africa, with marked rural disadvantage and strong protective effects of education and delayed childbearing. Recent systematic reviews and meta-analyses have reported global POI prevalence ranging from 3.5% to 3.7%, and this study findings align more closely with the evidence suggesting higher burdens in LMICs specifically, where developing countries demonstrate POI prevalence of 5.3% compared with 3.1% in developed nations.

A welcome review from Martina Pagliuca and colleagues covering survivorship after breast cancer treatment and the unique and complex set of challenges that extend well beyond the completion of active treatment.

It is a comprehensive overview of the long-term physical, psychological, reproductive, and social effects of breast cancer and its treatment highlighting the need for tailored, age-specific survivorship care.

The paper discusses multidisciplinary, patient-centered approach, integrating oncologic care with primary care, reproductive endocrinology, mental health services, and supportive care interventions. It underscores the importance of developing comprehensive survivorship strategies tailored to the specific needs of young breast cancer survivors, with the ultimate goal of improving long-term outcomes and enabling patients not only to survive but to thrive after breast cancer.

A big thank you to the authors for this important piece of work 🙏🏻

https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2026.1840152/full

Join us today at 7 pm online when we discuss optimising HRT for menopause

There are so many HRT options out there and so much of prescribing happens outside of product license in today’s world.

But what are the pros and cons of reach approach? Now do progestogens differ and what to do if someone is sensitive? Are all oral preparations equally thrombotic? What happens if bleeding persists despite multiple changes to HRT? Where does Tibolone fit in? Where are the combined pill or PO pill useful? Why does the breast risk differ in guidelines? So many tricky practical scenarios in day to day prescribing.
We will try and cover as much as we can today. Thank you Nigel Denby and Rowena Kivell 🙏🏻 for the opportunity.

https://your-menopause-by-harley-street-at-home.circle.so/c/upcoming-cpd-events/hrt-tweaks-adjustments-and-individualisation-for-best-care-outcomes-fce70c-e307910b-d501-4e84-8c9c-392e14069f4f

Here is a useful study from Leona A. Verma and Lauren A. Silvano which aimed to find out current confidence and knowledge of pharmacy students on menopause and HRT.

Pharmacy students at eight universities in the United Kingdom were invited by email to complete an online survey on menopause and hormone replacement therapy. Students were asked to self-report their confidence on each topic (0 = not confident at all, 10 = very confident), answer subject-specific questions and specify their preferred teaching methods. Data were analysed using descriptive statistics and a thematic approach where appropriate.

What was found?
In total 178 students (158 [88.8%] aged 18–24 years, 147 [82.6%] female) in years 1 (59, 33.1%), 2 (35, 19.7%), 3 (28, 15.7%) and 4 (56, 31.5%) completed the survey. Median [interquartile range] self-reported confidence in knowledge on menopause and hormone replacement therapy was 5.0 [4–6] and 4.0 [2–5], respectively. Students had basic knowledge of what menopause is, how long it lasts and common symptoms, but were uncertain about the risks and benefits of hormone replacement therapy. Students most commonly chose lectures (133/176, 75.6%) as their preferred teaching method.

The authors concluded that pharmacy students lack confidence in their own knowledge of menopause and hormone replacement therapy. Pharmacy schools must evaluate their current curricula and consider how these topics are taught, specifically the associated risks with hormone replacement therapy.

https://www.sciencedirect.com/science/article/pii/S1877129726001656?via%3Dihub

We presented our small research poster at the EGA Institute for Women’s Health ‘20th’ Annual Conference last year at the Senate House, University of London. A lot of hard work from Riya Philip on her survey project on Menopause in Medical Education. We had 100 responses and found that the majority of medical students in our survey felt that they needed more education on menopause. The results indicate a need for bigger studies looking into student’s and healthcare professional’s views on current teaching about menopause and a review of medical school curricula.

Here is a useful study from Leona A. Verma and Lauren A. Silvano which aimed to find out current confidence and knowledge of pharmacy students on menopause and HRT.

Pharmacy students at eight universities in the United Kingdom were invited by email to complete an online survey on menopause and hormone replacement therapy. Students were asked to self-report their confidence on each topic (0 = not confident at all, 10 = very confident), answer subject-specific questions and specify their preferred teaching methods. Data were analysed using descriptive statistics and a thematic approach where appropriate.

What was found?
In total 178 students (158 [88.8%] aged 18–24 years, 147 [82.6%] female) in years 1 (59, 33.1%), 2 (35, 19.7%), 3 (28, 15.7%) and 4 (56, 31.5%) completed the survey. Median [interquartile range] self-reported confidence in knowledge on menopause and hormone replacement therapy was 5.0 [4–6] and 4.0 [2–5], respectively. Students had basic knowledge of what menopause is, how long it lasts and common symptoms, but were uncertain about the risks and benefits of hormone replacement therapy. Students most commonly chose lectures (133/176, 75.6%) as their preferred teaching method.

The authors concluded that pharmacy students lack confidence in their own knowledge of menopause and hormone replacement therapy. Pharmacy schools must evaluate their current curricula and consider how these topics are taught, specifically the associated risks with hormone replacement therapy.

https://www.sciencedirect.com/science/article/pii/S1877129726001656?via%3Dihub

We presented our small research poster at the EGA Institute for Women’s Health ‘20th’ Annual Conference last year at the Senate House, University of London. A lot of hard work from Riya Philip on her survey project on Menopause in Medical Education. We had 100 responses and found that the majority of medical students in our survey felt that they needed more education on menopause. The results indicate a need for bigger studies looking into student’s and healthcare professional’s views on current teaching about menopause and a review of medical school curricula.

It has been busy few weeks of clinics and some reflections on the variations in advice we provide for menopause care.

A 54 year old who had stopped her periods for a year and was experiencing typical menopause symptoms presented to her healthcare provider. She had no background medical problems but was worried about the risk of breast cancer associated with oestrogen and progesterone use. She was counselled about the risk based on guidelines which suggested a risk with both oestrogen and progesterone part of HRT. She felt that the risk was not something she was comfortable with but did decide to seek an alternative opinion. This time she was presented with data and figures which suggested a reduced risk of breast cancer with oestrogen and slightly increased risk with the combination. She felt confused - who to believe!

Another woman who had considered systemic HRT for menopause at 55, less for symptoms but mainly for long-term health benefits was counselled by one healthcare professional about multiple benefits for long-term cognitive health, bone and cardiovascular health while another healthcare professional advised against HRT purely for long-team health benefits in absence of symptoms. She felt confused - who to believe!

A 45 year old woman saw her healthcare professional for symptoms suggestive of menopause and requested HRT but was advised against it as she continued to have monthly periods and she could put herself at a risk of excess hormones. She consulted an alternative provider who suggested that it was fine for her to start HRT and offered a prescription advising no such risks of excess hormones would apply to her. The woman felt confused - who to believe!

Yet another woman who had started continuous combined HRT for menopause in her 50s had started experienced bleeding in the 3rd month of initiating her HRT. She had had no bleeding for past 2 years. She saw her healthcare provider who referred her for an urgent ultrasound scan on a cancer pathway for postmenopausal bleeding. She was anxiously waiting for her scan appointment when another healthcare provider called her to cancel her scan and suggested that it was not uncommon to bleed in the first 6 months of starting HRT and that she no longer needs a scan now but a review later. She felt confused - who to believe!

There are even more examples. Navigating menopause care can be confusing for patients. We need to continue our efforts to support them in decision making based on the best possible scientific evidence we have and it can be challenging at times!

Congratulations 👏 to Dr Gayathri Delanerolle on publication of her latest book 📖

A thought provoking read about battles and challenges of medical menopause stemming from personal experiences and calling for reshaping of medical culture , research and policy through the lived truths of women.

Thank you Gayathri for this and also your amazing hardwork in making possible the Menopause and Ageing Research in International Environments (MARIE) study.
An amazing global collaborative effort across 13 countries to explore menopausal health across the world.

The findings of the study have highlighted the need for holistic, multidisciplinary, equity-focused menopause care and policy approaches beyond narrowly symptom-based models. We need real actions on ground that changes lives for better. Future research should prioritise longitudinal designs and culturally grounded approaches to better understand trajectories and inform integrated models of care.

https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(26)00285-3/fulltext

Here is a survey from Menopause and Cancer CIC (not-for-profit) designed to gather insights from individuals (age 18-30) who have experienced both menopause and cancer with the aim to better understand the unique challenges faced by this community and to use these findings to enhance the support available for those affected.

All responses are completely anonymous. You must be aged 18-30 years old to take part in this survey. If you have any questions, comments, or concerns, please contact - [email protected].
Please participate in the survey if you can or share with those who may be interested. Thank you for contributing to this research 🙏🏼.

Click to fill in or scan the QR code -
https://forms.cloud.microsoft/Pages/ResponsePage.aspx?id=8y1ywoOIqkup1ZOI4kKt2B5ITslOQvhElyTxa010jzlUNUgxWjYxOUtOU1NER0hJNEdDQzZEQ0dJTSQlQCN0PWcu