The Annual Conference of the British Menopause Society – June 2010

Abstract

The Annual Conference of the British Menopause Society was held on the 24th and 25th of June 2010 in a heritage type hotel, “Hotel Stratford Manor” in Stratford upon Avon, the birth place of Shakespeare. Beautiful Stratford is approximately 30–45 min by road from Birmingham. Dr. Sunila Khandelwal and I were representing the Indian Menopause Society at a collaborative session of the British Menopause Society and the Indian Menopause Society during this conference. Many interesting sessions were held during this 2-day meeting, with many new experiences and thoughts being presented, followed by stimulating discussions. The audience of approximately 300 delegates consisted of a mix of physicians from various specialties. A sizable number of them were family physicians who addressed many issues of Menopausal Medicine under the umbrella of the National Health Services (NHS) of the United Kingdom. The first day of the conference opened with a lecture by Mr. David Sturdee, the President of the International Menopause Society, who spoke on “Hot off the Press,” and gave an overview of the latest developments in the field of menopausal health. This was followed by a lecture by Nick Panay, who is also the Editor of the “Climacteric.” Nick discussed the issues related to “Bio Identical Hormones,” which are the new entrants in this field. He defined these hormones as precise duplicates of estradiol, progesterone and testosterone, similar to those synthesized by the human ovary. They are manufactured from plant sources in the laboratory and are available from pharma companies as micronized oral tablets, transdermal patches, implants and gels. Other possible delivery routes include nasal and wafer forms. He queried the sale of such unregulated products as the use of these products was not supported by evidence for efficacy or safety, especially because women who take these drugs, do so, without being monitored. A very enlightening talk by Dr. Geetha Subramanian traced the attitudes to menopause and bleeding through various religions and cultures. She referred extensively to “MUM,” the Museum of Menstruation, which was originally founded in America, and is now an online Museum available on www.mum.org. She further discussed medicalized menopause, hormone replacement therapy (HRT) in Ayurveda and ended with “offer them no flowers but instead a little estrogen.” The “Pat Patterson Lecture” was delivered by Prof. Roger Francis, Prof. of Geriatric Medicine on “Newer therapeutic options for the treatment of Osteoporosis.” He discussed the various options available, highlighting their advantages and disadvantages. He further described the newer therapeutics involving Rank and Rank ligand and discussed the results of clinical trials with Denosumab versus placebo. The trials carried out over 3 years involved 7,868 women between 60 and 90 years of age, with a bone mineral density score of 2.5 and 4.0, showeing a reduction of 80% in the fracture risk of the spine and an increase of 9% in bone density. He ended his talk by introducing future treatments for osteoporosis, involving Cathepsin K inhibitors, SARMs, Sclerostin Inhibitors and Calcilytics. “The Management of Premature Ovarian Failure” was presented by Dr. Beth Cartwright, Clinical Research Fellow of Kings College, London, highlighting the use of HRT in women with premature menopause at least until the age of natural menopause, which is 52 years in the United Kingdom. However, the optimal form of HRT is yet unknown in affected women due to the limited amount of clinical research carried out in this area. The above lectures were then followed by Oral Presentations by four speakers: “Efficacy of combined interferential therapy and hormone replacement therapy (HRT) in post menopausal urinary stress incontinence”- Dr. S. S Trivedi “Audit of two week referral for post menopausal bleeding and role of outpatient hysteroscopy”- Dr. Ketan Gajjar “Which HRT should be prescribed after subtotal hysterectomy (SH) and bilateral Salbingo- oophorectomy (BSO) in premenopausal women?”- Dr. William C. Mainer “Severe PMS and Bipolar Disease - a tragic confusion”- Mr. John Studd Congratulations to Dr. Trivedi who received an award for her Presentation at the Valedictory of the conference. We are all very proud of her! Menopause Café a concept similar to Roundtables, although a little different, was then held. Instead of Roundtables, where experts discuss a topic in depth along with 10–12 delegates on various tables, at the Café, the experts sat at various tables and the delegates walked around from table to table asking a question or two from the experts to solve their clinical dilemmas. I thought that this was a great way of delegates interacting with various experts to solve their relevant clinical queries rather than discussing a topic in depth. A very entertaining Debate on “This house believes that dietary supplements and “natural products” are suitable alternatives to HRT” was fought by Miss Joan Pitkin, Consultant Gynaecologist, Lead for Urogynaecology and Menopause, with Mr. John Studd, Professor of Gynaecology at Imperial College and Consultant Gynaecologist at Chelsea and Westminster Hospital, fighting against the motion. Joan Pitkin, dressed in a garb consisting of a black robe, headgear, a skull and a baton, pleaded her case so well that she won hands-down by convincing the audience that natural products are suitable alternatives to HRT. “The Cardiovascular (CVD) risk related to advancing age” “compounded menopause” was highlighted by the President of the IMS, Prof. Mary Ann Lumsden. She ended her talk by suggesting that borderline high blood pressure in women should be taken seriously as it could be the first sign of CVD; hot flushes, especially in obese women, may be associated with underlying heart disease; and to actively support management of obesity and diabetes in menopausal women to reduce cardiovascular risk. The concept of “Insulin Resistance and its influences on Menopause Management” was very efficiently introduced by Miss. Sovra Whitcroft, Consultant Obstetrician and Gynecologist, Guildford, UK, who highlighted the increasing insulin resistance with loss of hormones during menopause. She suggested, based on her pilot clinical research, that addition of Metformin to HRT would improve the response to HRT without dose increase in those women whose symptoms of insomnia and mood did not improve with only HRT. The BMS lecture on “Contraception in the perimenopause and the role of Intrauterine systems” was delivered by Prof. Anne Gompel from Paris. She highlighted the adverse effects of combined oral contraceptive pills in perimenopausal women, the permanent loss of reproductive function by sterilization and the heavy menstrual flow with the use of copper IUD in this age group. She focused on the advantages and side-effects of the intrauterine system, especially in reducing menorrhagia and controlling adenomyosis. She concluded her talk with describing the use of progestin-only contraception with molecules having antigonadotropic potencies, especially in women with metabolic problems and with increased risk of venous thrombosis. At the joint session of British Menopause and Indian Menopause Societies two members from the IMS presented the following talks: The metabolic aspects of postmenopausal women in India by Dr. Duru Shah prevalence of the metabolic syndrome was much higher in the postmenopausal as compared to the premenopausal women in the study by Dr. Shah [Table 1]. Psychosomatic health at menopausal transition by Dr Sunila Khandelwal She presented data of a multicentric, observational, cross-sectional study published by the Indian Menopause Society, involving 1,661 postmenopausal women, which has shown that the major problems encountered were hot flushes, depression and anxiety (47.26%). Table 1 Comparison of prevalence of metabolic syndrome in various regions This session was followed by a talk on “Migraine” by Dr. Anne MacGregor Director of Clinical Research at the Migraine Clinic, London, who suggested that migraine is a risk factor for onset of menopause symptoms. The prevalence of headache in a menopause clinic was approximately 57%, with 29% having migraine and 10% having a daily headache. Surgical menopause led to worsening headache in 67% of the women suffering from migraine versus only 9% in women who achieved natural menopause. In the WHI study, the risk of migraine increased with the use of HRT, the odds ratio varying between 1.39 and 1.42 with different types of HRT. The continuous combined HRT was the best tolerated regimen. She concluded with practical recommendations for managing menopause in woman with migraine with or without aura, as follows: No contraindication to use of HRT Use lowest effective dose to control vasomotor symptoms Transdermal route to be preferred to consider nonhormonal options if cure worsens To exclude transient ischemic attacks Alternatives to HRT could include: Isoflavones 40–80 mg/day SSRI/SNRI's – Fluoxetine 20 mg/day Venlafaxine 37.5–75 mg/day Gabapentin 300 mg three-times a day Exercise The last session of the BMS meeting focused on “Bladder Problems” in menopausal women presented by Mr. Philip Toozs-Hobson Consultant Urogynecologist from Birmingham Women's Hospital. He summarized the effects of age and menopause on the bladder and expressed the financial burden on continence care, with a large percentage of this cost being on symptomatic treatment rather than treating it. HRT use has been inconclusive for this problem, but topical estrogen leads to subjective improvement, probably due to various factors such as: Correction of urogential atrophy within the vagina so that soreness is reduced. Restoration of the premenopausal predominance of lactobacilli, which, in turn, reduces the occurrence of urinary tract infections. An alteration in the bladder sensory threshold due to a stabilizing effect on cellular depolarization A direct effect on the urethral sphincter and its blood vessels Treatment with estrogens however is best using the vaginal route as systemic therapy often leaves urogenital symptoms suboptimally treated. The entire Conference was an academic feast as it brought various specialties together, presenting their experiences and research and offering the delegates the latest scientific evidence on menopausal management.