Menopause, or menopause, is a change that happens and in some unspecified time in the future has a profound impact on the lives of half of the world’s population. Best practices for the clinical management of this transition were published previously in 2014 as a Practitioner’s Menopause Management Toolkit. A revised toolkit has been published that features more recently published findings on optimal clinical care.
The unique toolkit was intended to offer physicians with an easy-to-use framework for assessing and treating menopause-related conditions. It’s approved by the International Menopause Society and is used worldwide.
The authors of the revised 2023 Toolkit extracted key recommendations from skilled guidelines and position statements, in addition to consensus on menopause and related conditions, which have emerged since 2014.
Toolkit, published in Menopause, begins with a definition and a temporary description of the physiology and pathophysiology related to menopause. It outlines the symptoms of menopause that will or is probably not treated with menopausal hormone therapy (MHT), and guidelines for taking a history.
Based on current literature, it provides flowcharts to facilitate the diagnosis, assessment, and treatment of ladies affected by clinical conditions related to menopause.
It provides clinical algorithms to assist resolve whether a lady is in menopause or not. It also facilitates the selection of hormonal or non-hormonal therapy. Also covers newer therapies, subject to availability and regulatory restrictions that modify by country.
The toolkit provides a spectrum of management options that could be made available to a lady to assist her make shared decisions about her care. An example is the choice to make use of MHT in situations where there are not any current guidelines, resembling the prevention of fractures resulting from bone loss in asymptomatic postmenopausal women.
The toolkit has received praise from numerous skilled bodies for ladies’s menopausal health, including the International Menopause Society, the Australasian Menopause Society and the British Menopause Society.
Recognizing menopause
Menopause refers to “everlasting cessation of menstruation in a lady who has not had a hysterectomy” Nevertheless, while this will likely be scientifically accurate, it doesn’t cover women who don’t menstruate before menopause resulting from, for instance, hysterectomy.
This has led to a more reasonable definition of menopause as “everlasting cessation of ovarian function” The typical age ranges from 45 to 55 years in wealthy countries but is earlier in developing countries, requiring clinicians to make appropriate adjustments when diagnosing early menopause or premature ovarian insufficiency (POI) based on the Toolkit definitions.
The authors discuss the necessity for and relative accuracy of hormone testing as a predictor of menopause, in addition to the stages of menopause based on the menstrual cycle in accordance with the STRAW+10 classification developed by the Stages of Reproductive Aging Workshop (STRAW).
Differential diagnoses resembling thyroid disease or central causes of amenorrhea, in addition to conditions resembling iron deficiency which are related to nonspecific symptoms resembling fatigue, must also be excluded.
Symptoms related to menopause
Transition symptoms could also be attributable to a relative excess of estrogen, too little estrogen, or each. Many symptoms usually are not specific to menopause.
Symptoms related to estrogen deficiency include vasomotor symptoms (VMS), hot flashes, sweats, and urinary and reproductive symptoms. These are used as the idea for offering MHT.
VMS is reported by three-quarters of ladies who’ve undergone menopause and still occurs in one-third of ladies aged 65 to 80. These symptoms significantly worsen well-being, as does housing insecurity.
Moderate to severe VMS is related to thrice the chances of developing moderate to severe depressive symptoms in comparison with no VMS.
Other symptoms during this era include low mood, sleep disturbances, low libido, anxiety and irritability. Musculoskeletal symptoms during this era are more common in Asian women and infrequently reply to MHT.
Nevertheless, cognitive symptoms usually are not treated with MHT resulting from lack of evidence of effectiveness, and a research gap has been identified on this area.
Other changes related to decreased estrogen levels include visceral fat deposition, type 2 diabetes, heart problems, hyperlipidemia, and more rapid bone loss starting before the last menstrual period. The danger of fractures increases, and a few have also reported perimenopausal lack of verbal memory.
Treating the symptoms of menopause
Each lifestyle and medical management measures are discussed. Lifestyle risk aspects include good eating patterns, physical activity, avoiding smoking and excessive drinking, and relieving stress. Regular monitoring of cardiovascular risk aspects, including hypertension and high cholesterol, diabetes, and breast and reproductive system cancers, can be advisable.
MHT
In accordance with best clinical practice guidelines (CPG), hormone therapy during menopause is taken into account probably the most effective treatment for VMS. MHT must contain progestogen to guard the endometrium, if any, from cancer. Using oral estrogens increases the chance of venous thromboembolism (VTE), especially in people over 60 years of age, so the percutaneous route is preferred for high-risk women.
Androgens have limited use, in case of low libido only testosterone is indicated.
The mixture of estrogen and progesterone MHT is used to regulate VMS, sleep disorders, mood changes and urogenital dryness, in addition to musculoskeletal symptoms.
Combined MHT could be used cyclically, with scheduled monthly bleeds, or repeatedly if an LNG-IUD is inserted. The latter may cause breakthrough bleeding for several months, but 90% of ladies shouldn’t have a period after a 12 months.
After a complete hysterectomy, estrogen alone is used. Possible routes include oral implants, transdermal implants, vaginal rings, or pellet implants, although the latter is essentially unregulated. Pessaries and estrogen creams are suitable for the treatment of urogenital symptoms.
Other therapies include estrogen combined with a selective estrogen receptor modulator (SERM) as an alternative of progesterone and testosterone (alone to enhance libido). The effectiveness of MHT for VMS and sleep disorders has been documented, but not for depressive symptoms. Dietary and plant supplements usually are not useful for moderate to severe VMS, nor do they relieve exercise and stress.
Non-hormonal interventions with some effectiveness of cognitive behavioral therapy (CBT), which significantly alleviates VMS; and medicines with variable effectiveness resembling selective serotonin reuptake inhibitors and serotonin noradrenaline reuptake inhibitors, low dose oxybutynin, gabapentin, fezolinetant (a centrally acting drug) and clonidine. A highly expert surgical treatment called a stellate ganglion block also relieves severe VMS for up to a few months, but its availability is restricted.
Perimenopausal symptoms
Management of menstrual cycle disruptions, contraception and menopausal symptoms in perimenopausal women can be discussed. The combined oral contraceptive pill (COCP) helps in all three areas, but individual assessment is needed to reduce the chance of VTE and other antagonistic events.
In some countries, non-oral routes of administration can be found and alone help control cyclic bleeding. Women can switch to MHT after they not need COCP.
Levonorgestrel-releasing intrauterine devices (LNG-IUDs) are a progestin-only method that gives endometrial suppression. Minimizes bleeding in women affected by menorrhagia. They could be combined with estrogen and protect the endometrium for as much as five years.
Other progestin-only oral contraceptives may alleviate some symptoms and supply contraception when estradiol is contraindicated. Short-term progesterone can be useful for regulating cyclical bleeding.
MHT and osteopenia
MHT may help treat women with osteopenia before age 65 and other risk aspects for fractures. The authors also propose a bone density cutoff for recommending MHT, together with each woman’s body mass index (BMI) and time since menopause.
In postmenopausal women, MHT prevents bone fractures by stopping bone loss, no matter other risk aspects, and will be advisable in asymptomatic women over 65 years of age unless the chance is just too great.
MHT risk
Risks of systemic MHT use include VTE (with oral estrogen preparations) and breast cancer risk (with oral COCPs, but not estrogen alone). Progesterone is related to a lower risk of breast cancer than synthetic estrogens, but more evidence from randomized, controlled trials is required.
Tibolone, although mostly protected on this regard, barely increases the chance of ischemic stroke but reduces the chance of colon and breast cancer by ~70%.
Changing the treatment regimen often alleviates the antagonistic effects of MHT. Continued use of systemic MHT is advisable for evaluation, dose adjustment, testing, and discussion of patient drug-related concerns.
Application
“To our knowledge, it stays the one clinical practice tool within the care of menopausal women that has international application” The authors’ goal is to offer a baseline standard of evidence-based best care practices for each woman, no matter geographic or other limitations. The big selection of options it covers encourages clinicians to debate and educate women about their options before making a shared decision about their treatment.