Below is my personal view on the topic of ‘Menopausal medicine’. The driver for this commentary is the recently published Editorial discussing the NICE guidelines on the menopause .
Is there a Menopausal medicine ? No! There is not! Why? First, because menopause is only the date of the last menstrual period. Instead, I would prefer the term ‘Medicine of the climacteric woman’ to distinguish it from the ‘Medicine of the male climacteric’.
Under these circumstances, I might agree that there are some specific strategies to keep in mind when hormonal therapies are indicated. But these are well known. Indications and contraindications have been well documented and not much progress is to be anticipated in those areas. Then, how could I sum up what is my practice when I treat a climacteric woman? If she is hysterectomized and if she complains of distressing symptoms, I prescribe estrogens alone, preferably estradiol 17β-estradiol parenterally (patches, gels or implants), especially if triglycerides are elevated, or if there is a history of vascular disease. Conversely, I prefer an ester of estradiol by mouth if HDL cholesterol is low.
For those with an intact uterus, the above rules apply as well but with the addition of natural progesterone (or retroprogesterone) given sequentially or combined continuously.
Regular controls with mammography, pelvic ultrasound, blood pressure, blood analysis, weight are among the most important ones to decide whether to continue or to stop those treatments.
However, if looking after the health of a climacteric woman was only confined to the indications and contraindications of those hormonal treatments, I am sure this would not be enough for health promotion and disease prevention.
A new approach of modern medicine is what is known by Lifestyle medicine. And what is this? It is the teaching of the best practice of proper nutrition, exercise and mental health. The physician only teaches but it the woman that has to adopt such principles, as opposed to the conventional medicine where the active subject is the physician himself. Most physicians either do not believe or say that they have no time to teach Lifestyle medicine.
Harvard University is already heavily engaged in teaching physicians to practice Lifestyle medicine. It is noteworthy that 90% of deaths are due to errors in lifestyle! Prevention is better that cure. And this is the main obligation of all physicians, no matter what their specialty is. Helping women to improve their physical, mental and social well-being is the duty of anyone involved in the practice of holistic medicine.
Let it not be forgotten or overruled by what one may wrongly consider to be his obligation as a specialist in the medicine of climacteric women. I try only to be a good physician who takes care of the entire woman and not only of a part of her. Every attending physician has the obligation to have the time to deal empathically with that human being, to listen to her problems, for the support they need. He must always behave first as a compassionate human being, then as a physician who has an ample vision of medicine and, only finally as a good specialist.
These are the reasons why I do not consider myself as a specialist in the medicine of climacteric women. Let us all have the pleasure and honor of being good physicians. That is all the climacteric woman expects from us.
Clinica da Menopausa, Lisbon, Portugal
Hickey M, Banks E. NICE guidelines on the menopause (Editorial). BMJ 2016 Jan 18;352:i191