Managing the menopause: the question of evidence

In this issue of Climacteric, we have invited a wide variety of authors to submit manuscripts on a range of topics related to therapies for menopause management. We are especially grateful to the authors for submitting their manuscripts during this most difficult time of COVID-19. The therapies discussed in this issue reach from the very old to the newest concepts and originate from both Eastern and Western cultures. As such, we made a conscious editorial decision to take a liberal perspective on the data supporting some of the therapies, in order that the issue could be addressed more inclusively.

In the nearly three decades since the McMaster Medical School in Canada so named a new learning strategy, evidence-based medicine (EBM) has become a core standard for clinicians worldwide, particularly where ‘western’ medicine is practiced. EBM has taken over from other flawed approaches to learning including ‘eminence-based’, ‘vehemence-based’, ‘eloquence-based’ and ‘nervousness-based’ medicine (where decisions are based on fear of litigation rather than evidence)¹. Climacteric, its editors and reviewers are strong supporters of EBM and many of the papers in this issue reflect that position.

We were fortunate to be able to include an excellent review of vaginal lubricants and moisturizers, as well as papers on cognitive behavioral therapy for menopausal symptoms, testosterone use in postmenopausal women, and neurokinin-3 receptor antagonists. Most importantly, we were also able to provide our readers with a superb update on where we are today with menopausal hormone therapy.

In reflecting on our knowledge of menopausal hormone therapy over the last two decades, we are reminded of the Hegelian dialectic. To what extent we may have arrived at a higher level of knowledge is for the reader to determine. The paper by Langer et al.² in this issue provides guidance in that respect.

Compounding of pharmaceutical agents has existed for many years; however, compounding of menopausal hormone therapy agents appears to have exponentially accelerated in the post-Women’s Health Initiative era. This issue of Climacteric attempts to look at this topic from a variety of perspectives. Additionally, we were fortunate to be able to address the separate but related issue of bioidentical hormones. It should be noted in regard to compounded preparations that regulations covering the manufacture of compounded preparations may differ between states and nations and readers should take that into account.

In some areas, EBM is not perfect and there are more challenges to confront. Paramount amongst these is what to do when the evidence is lacking. There remain many examples of this in Western and Eastern medicine. Current advice is that, in these circumstances, we may accept the opinions of consensus panels of peers. Perhaps this is no better than the other parodies of EBM or so-called traditional medicine.

Another major challenge is accurate interpretation of the data. A cornerstone of EBM has been the development of systematic reviews and meta-analyses (SRMAs), intended to provide robust, reliable evidence to guide clinical practice. In the last two decades, there has been an explosion of SRMAs, leaving clinicians inundated with reviews, frequently on the same topic but with divergent results, because most are methodologically incomplete or redundant, giving rise to unhelpful or potentially biased information³. A clinician might thus modify clinical practice based on the reading of a particular SRMA (Level 1 evidence) without realizing that the results were biased. We must always read the literature with a critical eye⁴.

Almost all of the literature on menopausal hormone therapy is based on research in Western women. Despite this, Eastern cultures have made significant contributions to medicine and menopausal therapy specifically, and we are pleased that we have been able to provide our readers with articles addressing some of these, including discussions of what might be described as traditional medical practices.

The World Health Organization has developed a traditional medicine strategy which recommends further research toward understanding the effects and safety of traditional medicine. This journal supports that endeavor and the application of EBM wherever possible. For EBM to develop its full potential, it must investigate traditional medicine and take into account the wishes and beliefs of our patients. Most will not be familiar with double-blind, randomized, controlled trials, their strengths and weaknesses. In some places, patients may never have received conventional evidence-based treatment. Given that the concept of truth is determined by our upbringing, our values and beliefs and our prior knowledge, many of these patients, without due consultation, will elect for traditional treatment rather than EBM as we know it today⁵.

As health-care professionals, we must learn to think within the realms of evidence-based medicine and, at the same time, understand the views of our patients. Be skeptical but be open-minded, always looking for new evidence to help our patients. We hope you find some amongst this issue of Climacteric.

Potential conflict of interest

J.H.P. has served as a consultant to Pfizer, Shionogi, Sojournix, and TherapeuticsMD; and has stock options with TherapeuticsMD.

Source of funding

Nil.