Climacteric: past, present and future!

Our tenure as Editors-in-Chief of Climacteric is sadly drawing to a close. We would like to express our sincere gratitude to our Managing Editor, Jean Wright, and our Editorial Assistant, Susan Brown, without whom our editorial lives would have been much more difficult. We would also like to thank the Climacteric Editorial Board and the International Menopause Society Board whose paper-reviewing, written contributions and advice have been invaluable over the years. Most importantly, a journal is only as good as the contributions from its authors; we are most grateful to all those who have written papers for the journal, including original articles, reviews, commentaries and position statements. A thought also for our publishers who have respected our strict editorial independence and have been supportive of many of the projects we have suggested.

We hope that you, the readers, have enjoyed the offerings of the journal which we would like to think have been contemporary, cutting edge, controversial and widely appealing. As an International Society journal, we have tried to provide a mouthpiece for our affiliated menopause societies through publication of papers of regional origin that disseminate information of global relevance from which we can all benefit. We have also maintained a respectable impact factor through publication of cutting-edge, peer-reviewed research, commissioned review articles from key opinion leaders and state-of-the-art White papers, consensus statements¹ and recommendations². Supplements and special issues such as the decade post-WHI Climacteric issue in June 2012³ have attracted much professional and media attention, thereby putting menopause medicine on the map.

Over the last decade, we have seen a significant shift in the attitude and position of women, health-care professionals and the global societies concerned with midlife health. The concerns regarding hormone therapy, propagated by the media following the Women’s Health Initiative trials, are now starting to dissipate. They have been replaced with optimism that there may be a window of opportunity where it is possible to achieve primary prevention benefits. The crucial role of the perimenopause has become increasingly apparent in determining future health in the menopause. Optimizing perimenopausal health can improve not only quality of life but also reduce the future risk of metabolic syndrome, cardiovascular disease, malignancy, cognitive problems and early mortality. It is imperative that clinical research is now focused on long-term, randomized, prospective trials with standardized outcomes to confirm these benefits.

What developments do we hope to be reporting in the future? In order to optimize benefits and minimize side-effects and risks, targeted agents continue to be developed that are able to switch on receptors in tissues where this is desirable and avoid receptors in tissues such as the breast and endometrium. The ideal SERM (selective estrogen receptor modulator) which would be agonistic in the bone, cardiovascular system and urogenital tract and antagonistic in the endometrium and breast, whilst at the same time alleviating vasomotor and other menopause symptoms, does not yet exist. Research should now focus on fully understanding the processes that regulate the activity of the different estrogen receptor co-regulators. This will facilitate the development of SERMs with improved functional selectivity⁴.

Pharmacogenomic approaches will identify women with different requirements based on identification of genetic variants in enzymes involved in hormone metabolism and impacting hormone targets⁵. This will enable health-care professionals to select the right preparation, at the correct dosage, at the right time, for each individual in order to maximize effectiveness and minimize side-effects. However, the mechanisms by which environmental and biological factors also affect symptoms, possibly through epigenetic mechanisms, will need to be unraveled.

It can be argued that the ideal solution to menopause-related problems is to reverse the actual process. This was not thought to be possible due to irreversible loss of follicles and oocytes. However, recent research has demonstrated the possible presence of oogonial stem cells in adult ovaries. Work is now concentrating on initiating replication in these oogonial stem cells with a view to creating oocytes de novo⁶. This would be a particularly welcome breakthrough in young women with premature ovarian insufficiency.

Many of our doctors and nurses have become de-skilled in managing the menopause over the last decade, and menopause services have been withdrawn due to the media scares of the early 2000s. And yet, effective management of the menopause has never been as important as it is now, as our aging population increases both the health and economic burden on society. Economic expenditure to optimize health in the menopause must keep pace with the aging population. Menopause research must be given the due care, attention and resources that it deserves by governments, health departments and universities. Our departing hope is that our journal will continue to report exciting new developments at the forefront of menopause medicine research for many years to come.