Management of menopause: Key points
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Menopause is defined as 1 year of amenorrhea caused by decreased ovarian reserve or as the appearance of vasomotor symptoms in people with iatrogenic amenorrhea. It is preceded by perimenopause or the transition to menopause, which can last up to 10 years. Although there are many treatments for menopausal symptoms, fears around the risks of menopausal hormone therapy and a lack of knowledge about treatment options often prevent patients from receiving treatment.
This review summarizes the evidence for treating menopausal symptoms and discusses its risks and benefits to help guide doctors in evaluating and treating patients during the menopause transition.
Box 1: Evidence used in this review
We searched PubMed from inception to April 2022 using the term “menopause” with the keywords “symptoms,” “diagnosis,” and “treatment.” We also reviewed relevant articles from the reference lists of selected articles. The selected articles included a combination of systematic reviews, practice guidelines, randomized controlled trials, and cohort studies.
Hot flashes, night sweats, and sleep disorders are common symptoms of menopause that can affect health, quality of life, and work productivity. A new review published in CMAJ ( Canadian Medical Association Journal ) recommends menopause hormone therapy, historically known as hormone replacement therapy (HRT), as first-line treatment in people without risk factors.
Menopause symptoms can occur up to 10 years before the last menstrual period and can last more than 10 years, with negative effects for many people.
"Menopause and perimenopause may be associated with distressing symptoms and reduced quality of life," writes Dr. Iliana Lega, of Women’s College Hospital and the University of Toronto, Toronto, Ontario, with co-authors. "Menopause hormone therapy is the first-line treatment for vasomotor symptoms in the absence of contraindications."
The review summarizes the latest evidence for diagnosing and treating menopause symptoms, as well as the risks and benefits of therapies to help doctors and patients manage the condition.
"Although there are many treatments for menopausal symptoms, fears about the risks of menopausal hormone therapy and a lack of knowledge about treatment options often prevent patients from receiving treatment," the authors write.
The benefits of hormone therapy for menopause include
- Reduction of hot flashes in up to 90% of patients with moderate to severe symptoms.
- Improved blood lipid levels and a possible reduced risk of diabetes.
- Fewer fragility fractures of the hip, spine and other bones.
What about the risks?
- Although previous evidence has shown an increased risk of breast cancer, the risk is much lower in people ages 50 to 59 and in those who begin menopausal hormone therapy within the first 10 years of menopause.
- Some studies show an increased risk of ischemic stroke in women over 60 years of age who start therapy 10 years after the onset of menopause, but the risk is low for those under 60 years of age.
- For people with risk factors or those who do not want to receive menopausal hormone therapy, nonhormonal therapies, such as some selective serotonin reuptake inhibitors (SSRIs) and other medications, may help relieve symptoms.
"Despite initial concerns of an increased risk of cardiovascular events with menopausal hormone therapy following the Women’s Health Initiative trial, growing evidence shows a possible reduction in coronary artery disease with the therapy." menopausal hormone therapy among younger menopausal patients, specifically those who begin menopausal hormone therapy before age 60 or within 10 years of menopause," the authors write.
They emphasize that it is important for doctors to ask about symptoms before and during menopause and discuss treatments with patients based on their personal preferences and possible risk factors.
What are the considerations for starting hormone therapy for menopause?
For menopausal or perimenopausal patients of average age without contraindications to menopausal hormone therapy and without specific individual risk factors, no specific hormonal regimen is preferred for the management of menopause. When initiating a patient on menopausal hormone therapy, clinicians should consider the patient’s individual risk of disease (e.g., breast cancer, venous thrombolic events, stroke), preferred mode of administration (oral versus transdermal, combined versus separate dosing), the need for uterine protection and cost.
Patients with risk factors for specific diseases such as breast cancer should be offered an individualized regimen (e.g., TSEC, conjugated estrogen alone, combination therapy with cyclical progesterone). Similarly, a patient at risk for venous thromboembolic events should be offered low-dose transdermal therapy.
Common adverse effects of menopausal hormone therapy include vaginal bleeding, mastalgia, and headache. Unexpected vaginal bleeding is the most common adverse event with menopausal hormone therapy. Studies for endometrial hyperplasia or cancer (i.e., ultrasonography, endometrial sampling) should be performed if bleeding persists more than 4 to 6 months, or in a patient with risk factors for endometrial cancer.
It is not necessary to stop using menopausal hormone therapy while research is being done. Options to decrease unexpected vaginal bleeding include sequential progestin dosing (i.e., 12 to 14 days of the month); use of a levonorgestrel-releasing intrauterine system, tibolone, or TSEC (when available); or, in rare cases, hysterectomy. Evaluation of the endometrium with ultrasonography and histologic sampling, and titration of estrogen or progestin dosage based on thickness and histologic phase, can be performed with or without referral to a gynecologist based on the comfort of the treating physician.
Mastalgia is a common estrogenic adverse effect and may raise concerns about breast cancer. You will usually improve during the first 3 to 4 months of treatment. Approaches to managing mastalgia include minimizing estrogen to the lowest effective dose or using conjugated estrogens, cyclic progestin dosing, tibolone, or TSEC (when available).
Migraine is not a contraindication to the use of systemic menopausal hormone therapy. Migraine symptoms can be improved in some patients through regular and continuous use of doses of estrogen and progesterone. For patients with contraindications to menopausal hormone therapy, escitalopram and venlafaxine have evidence of improvement of vasomotor symptoms and suppression of migraine.50
Conclusion Menopause and perimenopause may be associated with distressing symptoms and reduced quality of life. Menopausal hormone therapy is the first-line treatment for vasomotor symptoms in the absence of contraindications. Patients with contraindications to estrogen and progestin therapy may be offered non-hormonal alternatives. The choice of menopause treatments depends on symptoms, patient preference, risk factors, absolute contraindications, availability, and costs. Complex patients should be referred to specialists. Important clinical questions remain unanswered and should be addressed by future research. |
Questions without answer
- What is the optimal duration of menopausal hormone therapy treatment?
- Are there superior hormonal formulations for cardiovascular or bone protection?
- What are the optimal hormonal formulations to minimize the risk of menopausal hormone therapy with respect to breast cancer and venous thromboembolic events?
- Will newer non-hormonal agents that act directly on brain receptors offer cardiovascular or bone protection?
- What is the workup for vasomotor symptoms suspected of not being of menopausal etiology?
- What is the evidence for non-pharmacological and lifestyle approaches to menopause management?
