Menopause

Diagnosis

Menopause is a clinical diagnosis that can only be made in retrospect one year after the last menstrual period. No laboratory evaluation is required to confirm a menopausal transition. Workup is indicated if other causes of symptoms or irregular menses are suspected (e.g., thyroid disease, other endocrine abnormalities, medication adverse effects, or drug intoxication or withdrawal).

Perimenopause can begin at age 40 to 50 and can last for 10 years. It is characterized by irregular menstrual cycles and vasomotor and vaginal symptoms.

Symptoms

Menopausal symptoms are caused by fluctuating hormone levels, notably a decrease in estrogen. The most common symptoms include the following:

• vasomotor symptoms: hot flushes, night sweats

• genitourinary syndrome of menopause: vaginal symptoms that include dryness, discharge, dyspareunia, itching, pain (previously known as atrophic vaginitis, vulvovaginal atrophy, or urogenital atrophy)

• other: change in sleeping patterns, urinary incontinence, depression, anxiety, fatigue, headache

Treatment Guidelines

Menopausal hormone therapy provides relief for hot flashes and night sweats and when administered locally addresses the symptoms of genitourinary syndrome of menopause. The following algorithm reflects the guidelines for hormone therapy in menopausal patients with vasomotor and genitourinary symptoms.

(Source: Hormone Therapy for Postmenopausal Women. N Engl J Med 2020.)

The following table summarizes recommendations for hormone therapy from various professional societies:

(Source: Hormone Therapy for Postmenopausal Women. N Engl J Med 2020.)

Notes on hormone therapy guidelines:

• The American College of Obstetricians and Gynecologists (ACOG) recommends that postmenopausal hormone therapy be used at the lowest dose for the shortest possible time for the treatment of menopausal symptoms. Data from observational studies suggest that transdermal estrogen is associated with a lower risk of venous thromboembolism than oral regimens.

• Current guidelines do not support the use of hormone therapy for reduction of cardiovascular risk or osteoporotic fracture risk.

• The U.S. Preventive Services Task Force (USPSTF) recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women, but they do not address use for treatment of menopausal symptoms.

• Endocrine Society guidelines recommend an individualized patient approach, weighing the risks of cardiovascular disease with the benefits of symptom reduction.

Treatment of Vasomotor Symptoms

First-line therapy for women with vasomotor symptoms is typically transdermal or transvaginal estrogen or low-dose paroxetine.

• Systemic hormone therapy with estrogen, either transdermally or orally, is the most effective therapy for severe vasomotor symptoms; women with a uterus require use of a progestin in combination with estrogen therapy to avoid endometrial proliferation.

  • Initial research on menopausal hormone therapy suggested possible reduction in overall mortality, cardiovascular events, and osteoporotic fractures.

  • Data from the Women’s Health Initiative in the United States and the Million Women Study suggested that postmenopausal estrogen and progestin administration is associated with an increased risk of coronary disease and invasive breast cancer.

  • However, more-recent evidence has shown no association between hormone therapy and risk of all-cause, cardiovascular, or cancer mortality.

  • Other research indicates that the benefits of hormone therapy may outweigh the risk for symptomatic younger women (<60 years old) and those who are <10 years from the onset of menopause.

• Nonhormonal options: Paroxetine (7.5 mg once daily) is FDA approved for treatment of systemic menopause symptoms.

  • Other selective serotonin­-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are also used.

  • Evidence for additional treatment is summarized below, in a table from the American Congress of Obstetricians and Gynecologists (ACOG) 2014 Practice Bulletin, and in guidelines from the North American Menopause Society.

• Alternative therapies: Many therapies such as gabapentin, acupuncture, yoga, Chinese herbs, ginseng, soy, and other alternative medicine have been studied, none of which have convincing evidence to support their use.

The following two tables summarize hormonal and nonhormonal treatment options for addressing menopausal vasomotor symptoms.

Treatment of Vaginal Symptoms

• Vaginal estrogens (creams, tablets, and rings) may be effective for vaginal dryness and dyspareunia, but there are concerns about their use in patients with estrogen-sensitive cancers and because they can be associated with vaginal bleeding.

• Nonhormonal vaginal moisturizers provide a reasonable alternative and can be beneficial in some women for symptom relief. Local preparations have minimal effect on serum estrogen levels and are therefore thought to be a safer option.

The following table summarizes treatment options for menopausal vaginal symptoms:

(Source: Practice Bulletin No 141: Management of Menopausal Symptoms. Obstet Gynecol 2014. Reprinted with permission.)