The question ‘Are we there yet?’ is one commonly asked in frustration at the apparently never-ending length of a journey. The same question might be asked of the long journey we have been on to improve the health and well-being of women in midlife and beyond, a journey inextricably linked to the history of the International Menopause Society (IMS).
Knowledge of post-reproductive life dates back more than 2000 years but, until the 20th century, there was little understanding of the underlying cause and even less of appropriate treatment.
The discoveries of estrogen by Allen and DoisyCitation1 in 1923 and of what became known as estrone by ButenandtCitation2 in 1929 were the start of a revolution in reproductive endocrinology which included the discovery of the other female sex hormone, progesteroneCitation3. This was followed, in 1941 in Canada and 1942 in the USA, by the release of a mixture of so-called ‘conjugated estrogens’, a relatively inexpensive product marketed with great success as ‘Premarin’Citation4.
Conjugated estrogens offered doctors a product that alleviated many of the symptoms of the menopause. Many writers of the time described menopausal women in the most pejorative of terms, spoke of the menopause as a ‘hormone deficiency disease’ and espoused the philosophy of estrogen for allCitation5. Hormone replacement therapy (HRT) was promoted to doctors, women and their partners as a safe, almost essential accompaniment to the menopause transition.
Whilst many benefited, there were certainly instances of inappropriate prescribing combined with a lack of understanding of the potential harms this may cause. Research was scant with only a handful of clinicians exploring the effects of menopause on bone and cardiovascular health.
In 1966 a young South African doctor, Wulf Utian, started a menopause clinic to investigate the clinical and metabolic effects of menopause and HRT. He published his findings to a small and distant audience but heard little until the early 1970s when he was contacted by Dr Pieter van Keep, based in Geneva. Van Keep had conducted research into sociocultural aspects of the menopause and suggested they meet to discuss collaborations. This happened in Switzerland in 1973. They became firm friends and decided to form a menopause club to attract colleagues and promote research. This menopause club flourished and led, in 1976, to the 1st International Congress on the Menopause.
Timing is everything and the decision to hold an international congress to define concepts of what was known and not known of the menopause and to plan future research came just after the publication of a paper in the New England Journal of Medicine reporting an increased risk of endometrial cancer associated with unopposed use of estrogen therapy. HRT had its first controversyCitation6.
The 2nd International Congress on the Menopause followed in 1978 and it was shortly after this that the International Menopause Society was formed, with a mission to ‘relieve sickness and preserve and protect good health by the promotion and co-ordination of information, education and scientific studies of the health and well-being of peri- and postmenopausal women during and after midlife’.
Since then, much progress has been made in our understanding of the menopause, of hormone therapies, of differences between ethnic groups, different cultures, and different regions of the world and, importantly, of what women want. A large body of evidence, accrued between 1978 and the end of the 20th century, suggested HRT, appropriately prescribed, offered many health benefits and few risks to women passing through the menopause transition. However, in 2002, the first results of the Women’s Health Initiative (WHI) randomized clinical trialCitation7 were released and appeared to contradict most of those earlier findings. As we all know, the following 14 years have seen many disagreements but also major revisions of those early findings, the publication of new important guidelinesCitation8–10 and a Global Consensus Statement on Menopausal Hormone TherapyCitation11.
During this time, the IMS has conducted 13 World Congresses on the menopause, offering a forum for debate and discussion, an opportunity to present scientific data for critique and for colleagues to mingle with and learn from experts from every corner of the globe. We have had differences, sometimes bitter, but, following the 15th World Congress, it is now clear that there is broad global agreement on the place of menopausal hormone therapy and also that we must work together for the well-being of our real constituency, women, world-wide.
In 1996, at the 8th International Congress on the Menopause, then IMS President Wulf Utian set a series of challenges for us to achieveCitation5.
He advocated the development of treatment guidelines for clinicians world-wide. This we have achieved through evidence-based documents from the IMS and national and regional societies and with the Global Consensus Statement.
He advocated a clearinghouse for exchange of information between societies. The IMS has an active educational outreach program to meet this challenge via our website, webinars, our weekly science update Menopause Live, our monthly communication, Our Menopause World, and our support of colleagues and societies world-wide. Our colleagues world-wide share in this work.
Very importantly, Dr Utian called for advocacy and universal preventative health-care strategies for all postmenopausal women. This is at the core of the IMS mission statement. We support the rights of women world-wide; we aim, through direct advocacy, provision of patient information and a global educational outreach program to make a difference.
Are we there yet? Sadly, we are not. Women in many parts of our world are still unequal citizens with unequal rights, unequal opportunity, unequal health care and unequal status.
As individuals our influence is small. As a global society dedicated to midlife women’s health, the IMS can and will continue to try, but we too are only a relatively small group. Our strengths are our links and friendships with our friends in national and regional societies around the world.
It is time to settle old differences and for all societies to work together for the good of the women of the world. Together we can make a difference.
References
- Allen E, Doisy A. An ovarian hormone. JAMA 1923;81:819–21
- Butenandt A. Uber Progynon ein kristallisiertes weibliches Sexualhormon. Naturwissenschaften 1929;17:879
- Allen W, Butenandt A, Corner G, Slotta K. Nomenclature of corpus luteum hormone. Science 1935;16:153
- Gaunt W. A preliminary report on a collaborative assay of conjugated oestrogen preparations. J Am Pharm Assoc 1953;42:173–6
- Utian WH. Pieter van Keep Memorial Lecture. Menopause – a modern perspective from a controversial history. Maturitas 1997;26:73–82
- Smith DC, Prentice R, Thompson DJ, Herrmann WL. Association of exogenous estrogen and endometrial cancer. N Engl J Med 1975;293:1164–7
- Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin therapy in healthy postmenopausal women. JAMA 2002;288:321–33
- Stuenkel C, Davis S, Gompel A, et al. Treatment of symptoms of menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015;100:3975–4011
- Lumsden MA, Davies M, Sarri G; Guideline Development Group for Menopause: Diagnosis and Management (NICE Clinical Guideline No. 23). Diagnosis and Management of Menopause: The National Institute of Health and Care Excellence (NICE) Guideline. JAMA Intern Med 2016;176:1205–6
- Baber R, Panay N, Fenton A, et al. 2016 IMS Recommendations on women’s midlife health and menopausal hormone therapy. Climacteric 2016;19:109–50
- De Villiers T, Hall J, Pinkerton J, et al. Global Consensus Statement on Menopausal Hormone Therapy. Climacteric 2016;19:313–15