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PRACTICE: Georgina Louise Jones, William Ledger, and Caroline Mitchell Suspected premature menopause BMJ 2008; 336: 833 [Full text]

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10 minute consultation:suspected premature menopause

Mohammad A Javid   (11 April 2008)

Highly Questionable Recommendation of HRT.

Mark D Lewars   (21 April 2008)

Re: Highly Questionable Recommendation of HRT.

Toby Nicholas Fay   (13 May 2008)

10 minute consultation:suspected premature menopause 11 April 2008
Mohammad A Javid, GP SA10 9BT Send response to journal: Re: 10 minute consultation:suspected premature menopause	This is an excellent article;it is practical and possible to carry out this consultation in the time-limited GP consultation. However I feel it would be more appropriate to list the patient's presenting symptom as oligomenorrhoea rather than irregular menses,the latter implying the presence of shorter and longer intermenstrual intervals. Competing interests: None declared
Highly Questionable Recommendation of HRT. 21 April 2008
Mark D Lewars, Consultant Radiologist Southend Breast Unit, S'end Univ Hospital NHST, Prittlewell Chase, Westcliff-on-Sea Essex SS00RY Send response to journal: Re: Highly Questionable Recommendation of HRT.	I thought we had laid to rest the myth that HRT has a beneficial cardiovascular effect. The American Women Health Initiative (WHI) study, published in 2002 (1), which was stopped short when it was recognised that combined HRT carried a 2.5 times risk of breast cancer compared with non- users, also showed not only failure to reduce, but an actual 29% increase in stroke and venous thrombosis. The same study showed the benefit in bone mineral density increase and reduction in fractures, but, as is well described in Middleton's review in RAD Magazine(2), a short course of HRT confers long term benefit. And it is the short course that is the only sensible recommendation, and only for severe menopausal side-effects, as the risk of breast cancer increases as the duration of therapy increases (3). If we add in the higher risk of recall for further investigation both from Breast and from Cervical Screening shown by the Million Women Study, with all the psychological distress so caused, then it appears irresponsible for Jones et al blandly to recommend combined HRT for 15 years or more. I sympathise with women who have menopausal symptoms, but find it hard to pass by advice that is so contrary to safe practice. References: 1. Roussouw J E, et al. Risks and benefits of oestrogen plus progestin in healthy post-menopausal women: Principal results. JAMA 2002 Jul 17; 288(3): 321-33. 2.Middleton E. The effect of short-term and low-dose hormone replacement therapy on long-term bone moineral density. RAD Magazine January 2008; 19. 3.BMJ 15 March 2008; Short Cuts. HRT associated with lasting risk of cancer.336:582/JAMA 2008;299:1036-45. Competing interests: None declared
Re: Highly Questionable Recommendation of HRT. 13 May 2008
Toby Nicholas Fay, Consultant Obstetrician & Gynaecologist Nottingham University Hospitals NHS Trust NG5 1PB Send response to journal: Re: Re: Highly Questionable Recommendation of HRT.	Dr Lewars could not be more ill-informed as the evidence he quotes is derived from women over 50 years of age and refers to normal menopausal women. To deny young women, who have been unfortunate enough to suffer premature menopause, the proven benefits of the successful treatment for the vasomotor and lower genital tract symptoms produce by hypo- oestrogenaemia, is arrant nonsense and would represent serious clinical negligence if she subsequently were to suffer serious vertebral or long bone fractures. The benefits of oestrogen replacement therapy for these young women far outweigh the unquantifed risks. Competing interests: None declared