EXECUTIVE SUMMARY
Despite the availability of effective hormonal and nonhormonal treatments for menopausal symptoms, few women with menopausal symptoms are evaluated or treated, reports a new scientific perspective.
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Since publication of initial findings from the Women’s Health Initiative in 2002, use of menopausal hormone therapy has declined steeply in U.S. women. However, clarification of the study’s evidence indicates that for most women in their 50s or within one decade of the onset of menopause, hormone therapy is safe.
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Professional societies, including the North American Menopause Society, the American College of Obstetricians and Gynecologists, and the Endocrine Society, support the use of systemic hormone therapy in symptomatic, recently menopausal women who do not have contraindications, such as an excess risk of breast cancer or cardiovascular disease, and who have a personal preference for such therapy.
By 2020, more than 50 million U.S. women will be older than 51, the mean age when menopause occurs.1 Despite the availability of effective hormonal and nonhormonal treatments for menopausal symptoms, few women with menopausal symptoms are evaluated or treated, reports a new scientific perspective.1 What can clinicians do to sharpen their clinical skills?
Providers who remain current regarding hormonal therapy can help their patients make sound choices regarding treatment of menopausal symptoms, observes Andrew Kaunitz, MD, University of Florida Research Foundation professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine – Jacksonville. The current perspective was co-authored by Kaunitz and JoAnn Manson, MD, DrPH, NCMP, chief of the Division of Preventive Medicine at Brigham and Women’s Hospital and professor of medicine and the Michael and Lee Bell professor of women’s health at Harvard Medical School, both in Boston.
Since publication of initial findings from the Women’s Health Initiative (WHI) in 2002, use of menopausal hormone therapy has declined steeply in U.S. women, notes Kaunitz. In contrast with current conventional wisdom, the best available evidence, which also comes from WHI findings, clarifies that for most women in their 50s or within one decade of the onset of menopause, hormone therapy is safe,2 says Kaunitz. (To review current treatment options, read the Contraceptive Technology Update article, “Update your treatment of menopausal symptoms,” December 2015, at http://bit.ly/1Ufat91.)
Notwithstanding the current evidence, hormone therapy (HT) is currently associated with such a “dark cloud of confusion and anxiety” that many symptomatic women who represent appropriate candidates for hormone therapy or nonhormonal management have difficulty finding clinicians who are knowledgeable and comfortable regarding treatment, states Kaunitz. “The purpose of our [article] was to signal the need for more education, (particularly for trainees, our next generation of providers) regarding menopause and appropriate strategies for treatment of symptoms, including HT and nonhormonal options,” he states.
Professional societies, including the North American Menopause Society (NAMS), the American College of Obstetricians and Gynecologists, and the Endocrine Society, support the use of systemic hormone therapy in symptomatic, recently menopausal women who do not have contraindications, such as an excess risk of breast cancer or cardiovascular disease, and who have a personal preference for such therapy.3-4 For patients in this category who present with moderate-to-severe vasomotor symptoms, a consensus has emerged that the benefits of hormone therapy are likely to outweigh the risks.1
For hot flashes, hormones are given in pills, patches, sprays, gels, or a vaginal ring for systemic therapy. For genitourinary symptoms, hormones are given in creams, pills, or rings that are inserted into the vagina.
The free MenoPro mobile app from NAMS facilitates personalized and shared decision-making for menopausal symptom management, notes Manson. (More information is available at http://bit.ly/1X1eGyK.)
The app allows the patient and the clinician to work together to personalize treatment decisions on the basis of the patient’s personal preferences, hormone versus non-hormone options, while taking into account the patient’s medical history and risk factor status. The app has two modes, one for clinicians and one for women, which facilitates shared decision-making.
This approach includes an assessment of whether the patient has moderate-to-severe menopausal symptoms, incorporation of the patient’s preferences regarding hormonal compared with nonhormonal therapy, and evaluation of the presence of contraindications to HT, explains Manson. The app also looks at the patient’s time since menopause onset and baseline risks of atherosclerotic cardiovascular disease, using an internal risk calculator that incorporates information on the patient’s age, smoking status, systolic blood pressure level, antihypertensive therapy, presence or absence of diabetes, and total and HDL cholesterol measurements. Other issues also are addressed, including the patient’s risk of breast cancer, osteoporosis, and other conditions relevant to clinical decision-making about HT initiation and duration of treatment. Information about treatment options, including regimens and doses, also is provided, notes Manson.
Other helpful features include links to NAMS education materials, such as a downloadable MenoNote on behavioral and lifestyle modifications to reduce hot flashes, as well as information pages on the pros and cons of hormone versus nonhormonal therapy options, a discussion of pill versus patch therapy, and information on treatment options for vaginal dryness and pain with sexual activities, with links to tables with information about different medications. These pages can be printed out or directly accessed from a phone or tablet.
REFERENCES
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Manson JE, Kaunitz AM. Menopause management — Getting clinical care back on track. N Engl J Med 2016; 374(9):803-806.
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Rossouw JE, Manson JE, Kaunitz AM, et al. Lessons learned from the Women’s Health Initiative trials of menopausal hormone therapy. Obstet Gynecol 2013; 121(1):172-176.
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Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2015; 100:3975-4011.
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Santen RJ, Stuenkel CA, Burger HG, et al. Competency in menopause management: Whither goest the internist? J Womens Health 2014; 23: 281-285.
