Menopause, or climacteric, is a change that occurs and profoundly affects the lives of half of the world’s population. Best practices for the clinical management of this transition have previously been published, in 2014, as the Practitioner’s Toolkit for Menopause Management. The revised toolkit has now been published, incorporating newly published findings for optimal clinical care.
The original toolkit was intended to present an easy-to-use framework for practitioners when evaluating and treating menopause-related conditions. It was approved by the International Menopause Society and is used worldwide.
The authors of the revised 2023 toolkit extracted key recommendations from professional guidelines and positions as well as consensus statements on menopause and related conditions that have emerged since 2014.
The Toolkit, published Climacteric, begins with definitions and an overview of menopause-related physiology and pathophysiology. It presents menopausal symptoms that may or may not be treated with menopausal hormone therapy (MHT) and guides the history taken.
Based on current literature, it includes flow charts for the diagnosis, evaluation, and management of women suffering from clinical conditions associated with menopause.
It provides clinical algorithms to decide whether a woman is menopausal or otherwise. It also guides the choice of hormonal or non-hormonal therapy. It also includes new therapies, subject to availability and regulatory restrictions that vary between countries.
The toolkit includes a spectrum of management options that can be shared with the woman to help her make shared decisions about her care. An example is the choice to use MHT in situations outside current guidelines, such as fracture prevention due to osteoporosis in asymptomatic postmenopausal women.
The toolkit has received praise from a number of professional organizations concerned with women’s health during menopause, including the International Menopause Society, the Australian Menopause Society and the British Menopause Society.
Menopause means “Permanent cessation of menstruation in women who have not been hysterectomized” However, while this may be academically correct, it does not cover women who do not menstruate before menopause, for example, due to a hysterectomy.
This has led to a more reasonable definition of menopause.”Permanent cessation of ovarian function“The average age varies between 45 and 55 years in rich countries but it is earlier in developing countries. Clinicians must make appropriate adjustments when diagnosing early menopause or premature ovarian insufficiency (POI) based on toolkit definitions.
The authors discuss the need and relative accuracy of hormone assays as predictors of menopause, as well as the menstrual cycle-based stages of menopause according to the STRAW+10 classification by the Stages of Reproductive Aging Workshop (STRAW).
Differential diagnoses should also be excluded, such as thyroid disease or a central cause of amenorrhea, as well as conditions such as iron deficiency associated with non-specific symptoms such as fatigue.
Symptoms during transition can be caused by a relative excess of estrogen or too little estrogen, or both. Many symptoms are not specific to menopause.
Those associated with estrogen deficiency include vasomotor symptoms (VMS), hot flushes, sweating, and urinary and reproductive tract symptoms. These are used as a basis for offering MHT.
VMS is reported in three-quarters of women who have gone through menopause and is present in one-third of women between 65 and 80 years of age. These symptoms significantly reduce well-being, as does housing insecurity.
Moderate to severe VMS is associated with a threefold greater likelihood of moderate to severe depressive symptoms than the absence of VMS.
Other symptoms of this period include low mood, sleep disturbances, low libido, anxiety and irritability. Musculoskeletal symptoms during this period are more common in Asian women and often respond to MHT.
In contrast, cognitive symptoms are not treated with MHT in the absence of evidence of efficacy, and a research gap has been identified in this area.
Other changes associated with decreased estrogen include visceral fat deposition, type 2 diabetes, cardiovascular disease, hyperlipidemia, and accelerated bone loss before menopause. Fracture risk is increased, and some have reported loss of verbal memory.
Management of menopausal symptoms
Both lifestyle and medical management measures are put in place. Lifestyle risk factors include good dietary patterns, physical exercise, avoidance of smoking and excessive alcohol consumption, and stress relief. Regular monitoring is recommended for cardiovascular risk factors including high blood pressure and high cholesterol, diabetes, and cancer of the breast or reproductive tract.
Menopausal hormone therapy, by best clinical practice guidelines (CPGs), is considered the most effective treatment for VMS. MHT must include a progestogen to protect the endometrium, whenever present, against cancer. Oral estrogen use increases the risk of venous thromboembolism (VTE), especially in those over 60 years of age, making the transdermal route preferable for high-risk women.
With limited use of androgens, only testosterone is indicated for low libido.
A combination of estrogen and progesterone MHT is used to control VMS, sleep disturbances, mood swings, and urogenital dryness, as well as muscle symptoms.
Combined MHT can be used cyclically, with scheduled bleeding every month or if there is an LNG-IUD. The latter may cause breakthrough bleeding for several months, but 90% are amenorrhoeic within a year.
Estrogen alone is used after total hysterectomy. Possible routes include oral, transdermal, vaginal ring or pellet implant, although the latter is mostly unregulated. Estrogen pessaries and creams are suitable for management of urogenital symptoms.
Other therapies include estrogen (alone to improve libido) in combination with a selective estrogen receptor modulator (SERM) instead of progesterone and testosterone. Efficacy of MHT has been documented for VMS and sleep disturbances, but not for depressive symptoms. Nutritional and herbal supplements are not useful for moderate to severe VMS, and neither are exercise and stress relief.
Non-hormonal interventions, including some effective cognitive behavioral therapy (CBT), significantly alleviate VMS; and variable efficacy such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, low-dose oxybutynin, gabapentin, phaseolinate (a centrally acting drug), and clonidine. A highly-efficient surgical procedure called stellate ganglion blockade also provides relief from severe VMS for up to three months but availability is limited.
Menstrual cycle disturbances, contraception, and management of menopausal symptoms in perimenopausal women are also prescribed. The combined oral contraceptive pill (COCP) helps in all three cases, but individual evaluation is essential to reduce the risk of VTE and other adverse events.
Non-oral routes of administration are available in some countries to help control cyclic bleeding only. Women can transition to MHT once they no longer need COCP.
The levonorgestrel-releasing intrauterine device (LNG-IUD) is a progestogen-only method that provides endometrial suppression. It reduces bleeding in women with menorrhagia. They can combine with estrogen and protect the endometrium for up to five years.
Other progestin-only oral contraceptives may relieve some symptoms and provide contraception when estradiol is contraindicated. Short-course progesterone is also effective in regularizing cyclical bleeding.
MHT and osteopenia
MHT can help treat women with osteopenia before age 65 who have other risk factors for fracture. The authors propose a bone density cut-off for recommending MHT, along with body mass index (BMI) and time since menopause for each woman.
For postmenopausal women, MHT prevents bone fractures by preventing bone loss regardless of other risk factors, and may be recommended for asymptomatic women over 65 if the risk is not high.
Risks of systemic MHT include VTE (for oral estrogen-containing formulations), and breast cancer risk (for oral COCPs but not estrogen alone). Progesterone carries a lower breast cancer risk than synthetic estrogen, but more evidence from randomized controlled trials is needed.
Tibolone, although mostly safe in this setting, slightly increases the risk of ischemic stroke but reduces the risk of colon and breast cancer by ~70%.
A change in regimen often relieves the adverse effects of MHT. Follow-up is recommended for systemic MHT to assess, adjust doses, test, and discuss patient problems with medication.
“To our knowledge, this is the only clinical practice tool for menopause-related care that has international application“The authors aim to provide a basic standard of evidence-based best care practice for any woman, regardless of geographic or other limitations. It covers a wide range of options, encouraging clinicians to discuss available choices and educate women before making a shared decision about their management.