menopause

Treatment of Vasomotor Symptoms

Alex Haga — Tue, 25 Feb 2025 17:46:04 +0000

Date Added:

February 25, 2025

Journal/Publication:

The Journal of the American Board of Family Medicine

Publication Date:

September 1, 2024

Issue:

Volume:

Pages:

923-932

URL:

Treatment of Vasomotor Symptoms

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.3122/jabfm.2023.230408R1

Keywords

MeSH

A review of treatment options for patients with vasomotor symptoms of menopause. James W. Mold, MD, MPH

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Vasomotor symptoms (VMS) related to the menopausal transition affect the majority of women and contribute to significant quality of life burden. Incidence, length, severity and report of symptoms vary by race, ethnicity, and coexisting health conditions. The pathophysiology of VMS is not fully understood and is likely multifactorial, involving changes in the hypothalamicpituitary-ovarian axis during the menopausal transition. Treatment approaches include lifestyle modifications, hormonal and non-hormonal therapies, including integrative and complementary medicine approaches. Systemic hormone therapy with estrogen is the most effective treatment. Emerging evidence suggests that treatment with SSRIs, SNRIs, and gabapentin is effective for many women who want to avoid hormone therapy. A shared decision approach to treatment decisions involves consideration of risks with treatment options and discussion of patient priorities.

Author/s:

Karina Atwell, Morgan White, Greta Kuphal, Makeba Williams, Sarina Schrager

Sexual Dysfunction in Women

Erin Blanchette — Mon, 26 Aug 2024 15:39:15 +0000

Date Added:

August 26, 2024

Journal/Publication:

The New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

August 22, 2024

Issue:

Volume:

391

Pages:

736-745

URL:

Sexual Dysfunction in Women

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1056/NEJMcp2313307

Keywords

Sexual Dysfunction

Estrogen Replacement Therapy

PMID (1):

39167808

MeSH

Estrogen Replacement Therapy

Hysterectomy

Libido

menopause

A review of what we think we know about sexual dysfunction in women across the lifespan. James W. Mold, MD, MPH

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The Clinical Problem
Because there is no universal definition of normal sexual function, what constitutes sexual difficulty is determined by a person’s subjective definition of unsatisfactory sexual well-being. The condition is usually described as unsatisfactory interest, arousal, orgasm, or other aspects of sexuality (e.g., sexual self-image), and the symptoms often coexist. The term “sexual dysfunction” is used when at least one of the symptoms is of substantial concern to the affected person. Sexual dysfunction negatively affects mental health, vitality, and social functioning and has an overall effect on quality of life that is of similar magnitude to that associated with chronic back pain or diabetes.

Author/s:

Susan R Davis

Genitourinary Syndrome of Menopause: A Systematic Review

Alex Haga — Tue, 20 Aug 2024 19:48:50 +0000

Date Added:

August 20, 2024

Journal/Publication:

Agency for Healthcare Research and Quality

Publication Date:

July 31, 2024

URL:

Genitourinary Syndrome of Menopause: A Systematic Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

Genitourinary

Genitourinary Syndrome

MeSH

An evidence-based review of strategies for managing the GU symptoms of menopause. James W. Mold, MD, MPH

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Objectives. To conduct a systematic review of evidence regarding genitourinary syndrome of menopause (GSM) screening, treatment, and surveillance.

Data sources. Ovid/Medline®, Embase®, and EBSCOhost/CINAHL® from database inception through December 11, 2023.

Review methods. We employed methods consistent with the Agency for Healthcare Research and Quality Evidence-based Practice Center Program Methods Guidance to identify studies and synthesize findings for Key Questions related to screening for GSM, effectiveness and harms of U.S.-available interventions for GSM, appropriate followup intervals for patients using GSM treatments, and endometrial surveillance for patients using hormonal GSM treatments. For vaginal estrogen and vaginal or systemic non-estrogen hormonal interventions, energy-based interventions, and vaginal moisturizers, we first assessed study quality and then, for moderate or high-quality studies, reviewed outcomes related to GSM symptoms, treatment satisfaction, and adverse effects. For low-quality studies, we described limited study characteristics only. For studies of other non-hormonal interventions, we created an evidence map describing study characteristics without assessing study quality.

Results. After assessing 107 publications for risk of bias (RoB), we extracted and synthesized effectiveness and/or harms outcomes from 68 publications describing trials or prospective, controlled observational studies that were rated low, some concerns, or moderate RoB (24 estrogen publications, 35 non-estrogen, 11 energy-based, and 4 moisturizers). Of 39 high, serious, or critical RoB publications, we extracted long-term harms from only 15 uncontrolled studies of energy-based interventions (all serious or critical RoB due to confounding). An additional 66 publications evaluating 46 non-hormonal interventions, including natural products, mind/body practices, and educational interventions, were described in an evidence map. Across all 172 publications, studies differed in GSM definitions, diagnosis, enrollment criteria, and outcomes assessed. Few studies enrolled women with a history of breast or gynecologic cancers. Overall, we found that vaginal estrogen, vaginal dehydroepiandrosterone (DHEA), vaginal moisturizers, and oral ospemifene may all improve at least some GSM symptoms, while evidence does not demonstrate the efficacy of energy-based therapies, vaginal or systemic testosterone, vaginal oxytocin, or oral raloxifene or bazedoxifene for any GSM symptoms. Harms reporting was limited, in part, by studies not being sufficiently powered to evaluate infrequent but serious harms, though most studies did not report frequent serious harms. Common non-serious adverse effects varied by treatment and dose. No studies evaluated GSM screening or directly addressed appropriate followup intervals or the effectiveness and harms of endometrial surveillance among women with a uterus receiving hormonal therapy for GSM. The longest followup period for active endometrial surveillance in an included trial was 12 weeks (vaginal estrogen) or 1 year (non-estrogen hormonal interventions).

Conclusions. This systematic review provides comprehensive, up-to-date information to guide patients, clinicians, and policymakers regarding GSM. Despite the breadth of included studies, findings were limited by several factors, including heterogeneity in intervention-comparator-outcome combinations. Future studies would be strengthened by a standard definition and uniform diagnostic criteria for GSM, a common set of validated outcome measures and reporting standards, and attention to clinically relevant populations and intervention comparisons. Lack of long-term data assessing efficacy, tolerability, and safety of GSM treatments leaves postmenopausal women and clinicians without evidence to guide treatment longer than 1 year.

The Women’s Health Initiative Randomized Trials and Clinical Practice

Alex Haga — Mon, 13 May 2024 21:25:57 +0000

Date Added:

May 13, 2024

Journal/Publication:

JAMA

Publisher:

JAMA

Publication Date:

May 1, 2024

URL:

The Women’s Health Initiative Randomized Trials and Clinical Practice

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2024.6542

Keywords

PMID (1):

38691368

A summary review of the results of the Womens Health Initiative Study pertaining to HRT, Vit D/calcium supplementation, and low-fat diet in menopausal women. James W. Mold, MD, MPH

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Importance: Approximately 55 million people in the US and approximately 1.1 billion people worldwide are postmenopausal women. To inform clinical practice about the health effects of menopausal hormone therapy, calcium plus vitamin D supplementation, and a low-fat dietary pattern, the Women's Health Initiative (WHI) enrolled 161 808 postmenopausal US women (N = 68 132 in the clinical trials) aged 50 to 79 years at baseline from 1993 to 1998, and followed them up for up to 20 years.

Observations: The WHI clinical trial results do not support hormone therapy with oral conjugated equine estrogens plus medroxyprogesterone acetate for postmenopausal women or conjugated equine estrogens alone for those with prior hysterectomy to prevent cardiovascular disease, dementia, or other chronic diseases. However, hormone therapy is effective for treating moderate to severe vasomotor and other menopausal symptoms. These benefits of hormone therapy in early menopause, combined with lower rates of adverse effects of hormone therapy in early compared with later menopause, support initiation of hormone therapy before age 60 years for women without contraindications to hormone therapy who have bothersome menopausal symptoms. The WHI results do not support routinely recommending calcium plus vitamin D supplementation for fracture prevention in all postmenopausal women. However, calcium and vitamin D are appropriate for women who do not meet national guidelines for recommended intakes of these nutrients through diet. A low-fat dietary pattern with increased fruit, vegetable, and grain consumption did not prevent the primary outcomes of breast or colorectal cancer but was associated with lower rates of the secondary outcome of breast cancer mortality during long-term follow-up.

Conclusions and relevance: For postmenopausal women, the WHI randomized clinical trials do not support menopausal hormone therapy to prevent cardiovascular disease or other chronic diseases. Menopausal hormone therapy is appropriate to treat bothersome vasomotor symptoms among women in early menopause, without contraindications, who are interested in taking hormone therapy. The WHI evidence does not support routine supplementation with calcium plus vitamin D for menopausal women to prevent fractures or a low-fat diet with increased fruits, vegetables, and grains to prevent breast or colorectal cancer. A potential role of a low-fat dietary pattern in reducing breast cancer mortality, a secondary outcome, warrants further study.

Author/s:

Manson, J.E., Crandall, C.J., Rossouw, J.E.

A pragmatic approach to the management of menopause

Aubrey Delammermore — Wed, 17 May 2023 05:00:00 +0000

Date Added:

May 17, 2023

Journal/Publication:

CMAJ

Publisher:

CMA Impact Inc

Publication Date:

May 15, 2023

Issue:

Volume:

195

Pages:

E677-72

URL:

A pragmatic approach to the management of menopause

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

37188372

Keywords

PMID (1):

10.1503/cmaj.221438

MeSH

A nice review of treatment options for patients with menopausal symptoms. James W. Mold, MD, MPH

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Menopause is defined as 1 year of amenorrhea caused by
declining ovarian reserve or as the onset of vasomotor
symptoms in people with iatrogenic amenorrhea. It is preceded
by perimenopause or the menopause transition, which can last
for as long as 10 years. Although many treatments exist for
menopausal symptoms, fears around the risks of menopausal
hormone therapy and lack of knowledge regarding treatment
options often impede patients from receiving treatment. In this
review, we summarize the evidence for treating menopausal
symptoms and discuss their risks and benefits to help guide
clinicians to evaluate and treat patients during the menopausal
transition (Box 1).
• Menopausal symptoms can occur for as long as 10 years before
the last menstrual period and are associated with substantial
morbidity and negative impacts on quality of life.
• Menopausal hormone therapy is indicated as first-line
treatment of vasomotor symptoms, and is a safe treatment
option for patients with no contraindications.
• Though less effective, nonhormonal treatments also exist to
treat vasomotor symptoms and sleep disturbances.
• It is critical that clinicians inquire about symptoms during the
menopause transition and discuss treatment options with
their patients.

Author/s:

Lega, I. C., Fine, A., Antoniades, M. L., Jacobson, M.

Management of Menopausal Symptoms: A Review

Aubrey Delammermore — Wed, 08 Feb 2023 06:00:00 +0000

Date Added:

February 8, 2023

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

February 7, 2023

Issue:

Volume:

329

Pages:

405-420

URL:

Management of Menopausal Symptoms: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.24140

Keywords

sweat

Acetates

Cardiovascular Diseases

Progestins

menopause

PMID (1):

36749328

MeSH

A review of what we know and the current official recommendations regarding assistance with menopausal symptoms. James W. Mold, MD, MPH.

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Importance: Menopause, due to loss of ovarian follicular activity without another pathological or physiological cause, typically occurs between the ages of 45 years and 56 years. During the menopausal transition, approximately 50% to 75% of women have hot flashes, night sweats, or both (vasomotor symptoms) and more than 50% have genitourinary symptoms (genitourinary syndrome of menopause [GSM]).

Observations: Vasomotor symptoms typically last more than 7 years and GSM is often chronic. Efficacious treatments for women with bothersome vasomotor symptoms or GSM symptoms include hormonal and nonhormonal options. Systemic estrogen alone or combined with a progestogen reduces the frequency of vasomotor symptoms by approximately 75%. Oral and transdermal estrogen have similar efficacy. Conjugated equine estrogens (CEE) with or without medroxyprogesterone acetate (MPA) were the only hormonal treatments for which clinical trials were designed to examine cardiovascular events, venous thromboembolism, and breast cancer risk. Compared with placebo, the increased risk of stroke and venous thromboembolism associated with CEE (with or without MPA) and breast cancer (with use of CEE plus MPA) is approximately 1 excess event/1000 person-years. Low-dose CEE plus bazedoxifene is not associated with increased risk of breast cancer (0.25%/year vs 0.23%/year with placebo). Bioidentical estrogens approved by the US Food and Drug Administration (with identical chemical structure to naturally produced estrogens, and often administered transdermally) also are available to treat vasomotor symptoms. For women who are not candidates for hormonal treatments, nonhormonal approaches such as citalopram, desvenlafaxine, escitalopram, gabapentin, paroxetine, and venlafaxine are available and are associated with a reduction in frequency of vasomotor symptoms by approximately 40% to 65%. Low-dose vaginal estrogen is associated with subjective improvement in GSM symptom severity by approximately 60% to 80%, with improvement in severity by 40% to 80% for vaginal prasterone, and with improvement in severity by 30% to 50% for oral ospemifene.

Conclusions and relevance: During the menopausal transition, approximately 50% to 75% of women have vasomotor symptoms and GSM symptoms. Hormonal therapy with estrogen is the first-line therapy for bothersome vasomotor symptoms and GSM symptoms, but nonhormonal medications (such as paroxetine and venlafaxine) also can be effective. Hormone therapy is not indicated for the prevention of cardiovascular disease.

Author/s:

Crandall, C. J., Mehta, J. M., Manson, J. E.

Compounded Bioidentical Hormone Therapy The National Academies Weigh In

Devin Evans — Mon, 21 Dec 2020 06:00:00 +0000

Date Added:

December 21, 2020

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

December 14, 2020

URL:

Compounded Bioidentical Hormone Therapy The National Academies Weigh In

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2020.7232

Keywords

menopause

hormone therapy

Menopausal women

PMID (1):

33315055

MeSH

menopause

Data Collection

Endocrinologists

A concise summary of the findings of the National Academy of Medicine regarding the safety and effectiveness of compounded bio-identical hormones for management of menopausal women. James W. Mold, MD, MPH

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After 21 months of data collection and analysis, the NASEM committee’s overarching conclusion was, “Given the paucity of data on the safety and effectiveness of cBHT…there is insufficient evidence to support the overall clinical utility of cBHT as treatment for menopause.”1(p9) Specific concerns included inadequate labeling requirements of cBHT preparations, paucity of reliable pharmacokinetic and bioavailability data, technical challenges with difficult-to-compound steroid hormones (particularly pellet therapies), and insufficient high-quality evidence to establish whether cBHT preparations are safe and effective. The committee further concluded that most marketing claims about safety and effectiveness are not supported by evidence from welldesigned, properly controlled studies. Incomplete adverse event reporting contributes to safety concerns. The committee acknowledged that in the absence of safety and effectiveness data for cBHT, patient preference should not be the sole driver for use.

Author/s:

Stuenkel, Cynthia A., Manson, JoAnn E.

Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence

John Bayhi — Sat, 31 Aug 2019 15:40:18 +0000

Date Added:

August 31, 2019

Journal/Publication:

The Lancet

Publisher:

Elsevier Ltd.

Publication Date:

August 29, 2019

URL:

Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/S0140-6736(19)31709-X

Keywords

MeSH

The relevant information for advising individual patients is covered in the Summary Interpretation section and the last two paragraphs of the Discussion (end of paper).

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Summary

Background

Published findings on breast cancer risk associated with different types of menopausal hormone therapy (MHT) are inconsistent, with limited information on long-term effects. We bring together the epidemiological evidence, published and unpublished, on these associations, and review the relevant randomised evidence.

Methods

Principal analyses used individual participant data from all eligible prospective studies that had sought information on the type and timing of MHT use; the main analyses are of individuals with complete information on this. Studies were identified by searching many formal and informal sources regularly from Jan 1, 1992, to Jan 1, 2018. Current users were included up to 5 years (mean 1·4 years) after last-reported MHT use. Logistic regression yielded adjusted risk ratios (RRs) comparing particular groups of MHT users versus never users.

Findings

During prospective follow-up, 108 647 postmenopausal women developed breast cancer at mean age 65 years (SD 7); 55 575 (51%) had used MHT. Among women with complete information, mean MHT duration was 10 years (SD 6) in current users and 7 years (SD 6) in past users, and mean age was 50 years (SD 5) at menopause and 50 years (SD 6) at starting MHT. Every MHT type, except vaginal oestrogens, was associated with excess breast cancer risks, which increased steadily with duration of use and were greater for oestrogen-progestagen than oestrogen-only preparations. Among current users, these excess risks were definite even during years 1–4 (oestrogen-progestagen RR 1·60, 95% CI 1·52–1·69; oestrogen-only RR 1·17, 1·10–1·26), and were twice as great during years 5–14 (oestrogen-progestagen RR 2·08, 2·02–2·15; oestrogen-only RR 1·33, 1·28–1·37). The oestrogen-progestagen risks during years 5–14 were greater with daily than with less frequent progestagen use (RR 2·30, 2·21–2·40 vs 1·93, 1·84–2·01; heterogeneity p<0·0001). For a given preparation, the RRs during years 5–14 of current use were much greater for oestrogen-receptor-positive tumours than for oestrogen-receptor-negative tumours, were similar for women starting MHT at ages 40–44, 45–49, 50–54, and 55–59 years, and were attenuated by starting after age 60 years or by adiposity (with little risk from oestrogen-only MHT in women who were obese). After ceasing MHT, some excess risk persisted for more than 10 years; its magnitude depended on the duration of previous use, with little excess following less than 1 year of MHT use.

Interpretation

If these associations are largely causal, then for women of average weight in developed countries, 5 years of MHT, starting at age 50 years, would increase breast cancer incidence at ages 50–69 years by about one in every 50 users of oestrogen plus daily progestagen preparations; one in every 70 users of oestrogen plus intermittent progestagen preparations; and one in every 200 users of oestrogen-only preparations. The corresponding excesses from 10 years of MHT would be about twice as great.

Funding

Cancer Research UK and the Medical Research Council.

Author/s:

Collaborative Group on Hormonal Factors in Breast Cancer

Diagnosing Menopause

John Bayhi — Tue, 23 Jul 2019 19:17:47 +0000

Date Added:

July 23, 2019

Journal/Publication:

JAMA Clinical Reviews Podcast

Publisher:

American Medical Association

Publication Date:

July 22, 2019

URL:

Diagnosing Menopause

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Web Page

Keywords

menopause

A 15-minute audio review of menopause. James W. Mold, MD, MPH

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Menopause is inevitable for women. Its symptoms are uncomfortable and distressing. For women to best cope with menopause, it is useful to firmly establish the onset so that appropriate counseling can follow. In this podcast, an expert in this field, Nanette Santoro, MD, from the University of Colorado, explains how to diagnose menopause.

Menopausal Hormone Therapy

Tracy Ashby — Thu, 30 May 2019 05:00:00 +0000

Date Added:

June 5, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

May 30, 2019

URL:

Menopausal Hormone Therapy

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2019.5346

Keywords

MeSH

A concise review of post-menopausal hormonal therapies. James W. Mold, MD, MPH

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Hormone therapy is the most effective treatment for managing menopausal vasomotor symptoms. Hot flashes and night sweats affect approximately 70% of midlife women and may persist for a decade or longer.1 Bothersome vasomotor symptoms have a significant adverse effect on sleep, daily functioning, and quality of life. Cognitive and mood symptoms often accompany disruptive hot flashes. Although lifestyle changes and nonhormonal options are available, women with frequent, severe vasomotor symptoms may greatly benefit from hormone therapy.2

Author/s:

Shifren, Jan L., Crandall, Carolyn J., Manson, JoAnn E.