Associate Prof Dr Nik Hazlina Nik Hussain

Asia-Pacific Menopause Federation is a federation of 14 member national societies from across the Asia-Pacific region.

Decision-making regarding the menopause
Each woman should be given the opportunity to participate in the decision-making process with respect to menopause management including hormone replacement therapy (HRT).
 
Indications for Hormone Replacement Therapy (HRT)

• HRT is recommended as the primary and most important option to alleviate menopausal symptoms (vasomotor symptoms, sleep disturbances associated with vasomotor symptoms, and urogenital complaints).
• By decreasing menopausal symptoms, HRT may improve the overall health-related quality of life.

HRT Dosage recommendation

• The lowest effective dose consistent with treatment goals should be used.

Duration of therapy

• HRT should be given for as long as the benefits outweigh the risks and should be periodically assessed.
• The greatest benefits of HRT occur whenit is initiated during the menopausal transition or in the early menopause.

Rationale for adjunctive progestogen

• In women with a uterus, oestrogen therapy causes a dose- and duration-dependent increase in the risk of endometrial cancer.
• Adjunctive progestogen may be given continuously or cyclically, e.g. for 12 days
  each month.

Vaginal Oestrogen Therapy

• Oestrogen therapy improves urogenital changes of the menopause.
• Most vaginal oestrogens produce minimal rises in serum oestradiol and the potential for endometrial proliferation with long- term use seems very low.

Androgen Therapy

• Menopausal women (especially after bilateral oophorectomy) complaining of distressing low sexual desire (hypoactive sexual desire disorder) and/or unexplained tiredness persisting after adequate oestrogenization may be counselled about the possibility of testosterone supplementation.
   
  The long-term safety of androgen treatment has not been adequately studied.

Alternatives to hormone therapy

• Women choosing to use complementary and alternative medicines to relieve menopausal symptoms should be made aware that the efficacy is less than that of
  HRT and quality control is questionable.

Premature menopause (under age 40 years)

• Women with premature menopause have special needs and may require additional
  counselling.

Recommended Initial Assessment for peri- or postmenopausal women

• The Consensus group emphasized the need to educate all healthcare professionals and postmenopausal women regarding the management of the menopause including HRT.
• Initial assessment by any practicing healthcare professional should include:
  History:
  symptoms
  general medical history
  gynaecological history
  family history (especially malignancy)
  sexual history
  risk factors for menopause related diseases such as osteoporosis
   
  Examination:
  general, including weight, height and blood pressure
  breast, pelvic examinations
   
  Investigations: Advised only
  Pap or cervical smear, Complete blood count, Fasting blood sugar, Fasting Lipid
  profile
   
  Other investigations:
  to be ordered on a case to case basis could include: Liver function tests, thyroid
  function tests, mammography, bone mineral density, pelvic ultrasonography

Recommended Management at Follow-Up

• History: including response to treatment, side-effects and related problems
• Examination: Blood pressure, weight, height, breast and pelvic examination
• Investigations: Fasting lipid profile, Fasting blood glucose, pap or cervical smear (as per local guidelines)
• Other investigations: to be ordered on a case-to-case basis could include liver function tests, thyroid function tests, mammography, bone mineral density, pelvic ultrasonography

Frequency of Follow-Up
In rural areas in many Asia-Pacific countries, there is a lack of state-of-the art medical facilities and instrumentation, such as equipment for mammography and bone mineral density.

• Therefore, while encouraging medical surveillance to the fullest extent possible, the Consensus Group considered it inappropriate to provide generally applicable guidance on frequency of medical assessments prior to and during HRT.
• Whenever possible, at least annual re-assessment is advised.

Resources
Resources used in the preparation of this statement include:

• Guidelines for hormone replacement therapy of Asian women during the menopausal transition and thereafter. Climacteric 2006;9:146-151.
• IMS Updated Recommendations on postmenopausal hormone therapy. Climacteric 2007;10:181-1.
• Updated practical recommendations for hormone replacement therapy in the peri and postmenopause. Climacteric 2008;11:108-123.
• Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database System Review 2006 Oct 18;(4):
  CD001500.
• Data presented for each country by the national representatives at the Consensus Meeting.

Declaration

• The APMF Consensus meeting was supported by unrestricted educational grants from Bayer Healthcare, Wyeth Pharmaceuticals, Organon (Schering- Plough) and Novo Nordisk (Australia).
• No representatives of these companies were present during the discussions and development of the statement.