Managing menopause.

OBJECTIVE:

To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality.

OUTCOMES:

Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are reviewed. Approaches to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline.

EVIDENCE:

Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary (e.g., hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e.g., hormone therapy, perimenopause, heart disease, and sexuality). Results were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to publication dates of 2009 onwards and to material in English or French. Searches were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice guideline collections.

VALUES:

The quality of the evidence in this document was rated using the criteria described by the Report of the Canadian Task Force on Preventive Health Care (Table). Summary Statements and Recommendations Chapter 1: Assessment and Risk Management of Menopausal Women Recommendations for Patients 1. Women aged 51 to 70 should consume 7 servings of vegetables and fruits, 6 of grain products, 3 of milk and alternatives, and 2 of meat and alterna-tives daily. (III-A) 2. A diet low in sodium and simple sugars, with substitution of unsaturated fats for saturated and trans fats, as well as increased consumption of fruits, vegetables, and fibre, is recommended. (I-A) 3. Routine vitamin D supplementation and calcium intake for all Canadian adults year round is recommended. (I-A) 4. Achieving and maintaining a healthy weight throughout life is recommended. (I-A) 5. Women aged 18 to 64 should accumulate at least 150 minutes of moderate to vigorous aerobic physical activity per week in bouts of 10 minutes or more. (I-A) Recommendations for Health Care Providers 1. A waist circumference ≥ 88 cm (35 in) for women is associated with an increased risk of health problems such as diabetes, heart disease, and hypertension and should be part of the initial assessment to identify risk. (II-2A) 2. Tobacco-use status should be updated for all patients on a regular basis, (I-A) health care providers should clearly advise patients to quit, (I-C) the willingness of patients to begin treatment to achieve abstinence (quitting) should be assessed, (I-C) and every tobacco user who expresses the willingness to begin treatment to quit should be offered assistance. (I-A) 3. Blood pressure should be assessed and controlled as women go through menopause. (II-2B) If the systolic blood pressure is ≥ 140 mmHg and/or the diastolic blood pressure is ≥ 90 mmHg, a specific visit should be scheduled for the assessment of hypertension. (III-A) 4. Women ≥ 50 years of age or postmenopausal and those with additional risk factors, such as current cigarette smoking, diabetes, and arterial hypertension, should have lipid-profile screening done. (II-2A) 5. A cardiovascular risk assessment using the Framingham Risk Score should be completed every 3 to 5 years for women aged 50 to 75. (II-2A) 6. A history of past pregnancy complications (preeclampsia, gestational hypertension, gestational diabetes, placental abruption, idiopathic preterm delivery, and/or fetal growth restriction) should be elicited since it can often predict an increased risk for premature cardiovascular disease and cardiovascular death and may inform decisions about the need for screening. (II-2B) Chapter 2: Cardiovascular Disease Recommendations 1. Health care providers should not initiate hormone therapy for the sole purpose of preventing cardiovascular disease (coronary artery disease and stroke) in older postmenopausal women since there are no data to support this indication for hormone therapy. (I-A) 2. The risk of venous thromboembolism increases with age and obesity, in carriers of a factor V Leiden mutation, and in women with a history of deep vein thrombosis. Transdermal therapy is associated with a lower risk of deep vein thrombosis than oral therapy and should be considered only if the benefits outweigh the risks. (III-C) Health care providers should abstain from prescribing oral hormone therapy for women at high risk of venous thromboembolism. (I-A) 3. Health care providers should initiate other evidence-based therapies and interventions to effectively reduce the risk of cardiovascular disease events in women with or without vascular disease. (I-A) 4. Risk factors for stroke (obesity, hypertension, elevated cholesterol levels, diabetes, and cigarette smoking) should be addressed in all postmenopausal women. (I-A) 5. If prescribing hormone therapy to older postmenopausal women, health care providers should address cardiovascular risk factors; low- or ultralow-dose estrogen therapy is preferred. (I-B) 6. Health care providers may prescribe hormone therapy to diabetic women for the relief of menopausal symptoms. (I-A) Chapter 3: Menopausal Hormone Therapy and Breast Cancer Recommendations 1. Health care providers should periodically review the risks and benefits of prescribing hormone therapy to a menopausal woman in light of the association between duration of use and breast cancer risk. (I-A) 2. Health care providers may prescribe hormone therapy for menopausal symptoms in women at increased risk of breast cancer with appropriate counselling and surveillance. (I-A) 3. Health care providers should clearly discuss the uncer-tainty of risks associated with systemic hormone therapy after a diagnosis of breast cancer in women seeking treatment for distressing symptoms (vasomotor symptoms or vulvovaginal atrophy). (I-B) Chapter 4: Vasomotor Symptoms Recommendations 1. Lifestyle modifications, including reducing core body temperature, regular exercise, weight management, smoking cessation, and avoidance of known triggers such as hot drinks and alcohol, may be recommended to reduce mild vasomotor symptoms. (I-C) 2. Health care providers should offer hormone therapy, estrogen alone or combined with a progestin, as the most effective therapy for the medical management of menopausal symptoms. (I-A) 3. Progestins alone or low-dose oral contraceptives can be offered as alternatives for the relief of menopausal symptoms during the menopausal transition. (I-A) 4. Non-hormonal prescription therapies, including certain antidepressant agents, gabapentin, and clonidine, may afford some relief from hot flashes but have their own side effects. These alternatives can be considered when hormone therapy is contraindicated or not desired. (I-B) 5. There is limited evidence of benefit for most complementary and alternative approaches to the management of hot flashes. Without good evidence for effectiveness, and in the face of minimal data on safety, these approaches should not be recommended. Women should be advised that, until January 2004, most natural health products were introduced into Canada as "food products" and did not fall under the regulatory requirements for pharmaceutical products. As such, most have not been rigorously tested for the treatment of moderate to severe hot flashes, and many lack evidence of efficacy and safety. (I-B) 6. Estrogen therapy can be offered to women who have undergone surgical menopause for the treatment of endometriosis. (I-A) Chapter 5: Urogenital Health Recommendations 1. Conjugated estrogen cream, an intravaginal sustained-release estradiol ring, and low-dose estradiol vaginal tablets are recommended as effective treatment for vaginal atrophy. (I-A) 2. Routine progestin co-therapy is not required for endometrial protection in women receiving vaginal estrogen therapy in an appropriate dose. (III-C) 3. Vaginal lubricants may be recommended for subjective symptom improvement of dyspareunia. (II-2B) 4. Because systemic absorption of vaginal estrogen is minimal, its use is not contraindicated in women with contraindications to systemic estrogen therapy, including recent stroke and thromboembolic disease. (III-C) However, there are currently insufficient data to recommend its use in women with breast cancer who are receiving aromatase inhibitors (where the goal of adjuvant therapy is a complete absence of estrogen at the tissue level). Its use in this circumstance needs to be dictated by quality-of-life concerns after discussion of possible risks. (III-C) 5. Systemic estrogen therapy should not be recommended for the treatment of postmenopausal urge or stress urinary incontinence given the lack of evidence of therapeutic benefit. (I-A) Vaginal estrogen may, however, be recommended, particularly for the management of urinary urge incontinence. (II-1A) 6. As part of the management of stress incontinence, women should be encouraged to try non-surgical options, including weight loss (in obese women). (I-A) Pelvic floor physiotherapy, with or without biofeedback, (II-1B) weighted vaginal cones, (II-2B) functional electrical stimulation, (I-B) and/or intravaginal pessaries (II-2B) can also be recommended. 7. (ABSTRACT TRUNCATED)