Thursday morning of IMS 2018 started with The European Progestogen Club's Update on Menopause. The organisation was established in 1996; to date it has a published 144 publications and held 25 symposia. Following a brief introduction, Alfred Mueck, Sven Skouby and Lydia Marie-Scemama gave individual presentations.
Choice of progestogen in HRT - Alfred Mueck
Alfred Mueck, President of the German Menopause Society explored the four main risk factors associated with progestogen use in patients:
- Venous thromboembolism (VTE)
- Myocardial infarction (MI)
- Breast cancer
Mueck explained that the most important effects which may be dependent on the choice of the progestogen in HRT are an increase in MI and stroke.
Additionally, some minor negative progestogen effects also should be considered regarding the risk of VTE whereby the more important impact is derived from the oestrogen component. However, the most important detrimental effect may be the possible increase of breast cancer risk - with doctors and patients alike both sharing this fear.
Progestogen's increased risk of breast cancer has been attributed to its ability to bind to certain membrane-bound proteins and increase cell proliferation. Interestingly, if baseline proliferation is low, the protective effects of progestogen outweigh excessive division. However, this balance is altered when baseline proliferation is high.
Progestogens and the haemostatic system. The clinical translation - Sven Skouby
Heightened publicity surrounding hormone contraception and post-menopausal HT in regards to thrombosis risk has led to multidisciplinary discussions on the impacts of progestogens. The risk is affected by oestrogen combination, type of progestogen, mechanism of delivery and length of therapy.
Risk factors include family/personal history, covering pharmacogenomics and environmental modifiable epigenetics factors as well as drug interactions.
The largest existing meta-analysis of 8 observational studies did not identify any association between oral progestin-only contraception and risk of VTE. Neither was any risk associated to the use of the LNS system.
However, subgroup analysis suggests that injectable progestin contraception is associated with an approximate twofold increased risk of VTE relative to women not taking hormonal contraception.
Endometriosis and the menopause - Lydia Marie-Scemama
Vice president of the AFEM, Lydia posed the question: does endometriosis persist after menopause?
Lydia explained there are two common misconceptions in regards to endometriosis:
- It only affects pre-menopausal women. Persistence or recurrence of pre-existing disease, de-novo development, environmental factors and stress are some of examples of possible causes in post-menopausal women.
- Endometriosis is not related with ovarian cancer.
Endometriosis is in fact strongly associated with the increased risk of ovarian cancer, although the cancer typically shows favourable characteristics including early-stage disease, low-grade disease and a specific histology.
Medical treatment for post-menopause endometriosis includes second line aromatase inhibitors and levonorgestrel-IUD. It should be noted that HRT increase the risk - it is imperative to weigh up the risk-benefit.