The Endocrine Society’s new clinical practice guideline on the treatment of menopause symptoms advocates an individualized approach based on patient preferences and risk/benefit considerations.
“We wanted to focus on the treatment of symptoms of menopause,” Cynthia A. Stuenkel, MD, chair of the task force charged with drafting the guideline, said during a virtual press conference. “We, however, take a very individualized clinical approach. We want to know how bothered is that women and what does she want to do? Women vary greatly in their own personal preferences about how they would like to manage their symptoms.”
“Finally, we recognized as internists and endocrinologists that we need to be very mindful of individual health concerns of our patients really to answer the question: Is the particular therapy that we choose going to be safe for her?” she continued.
Menopause is often characterized by vasomotor symptoms, which include hot flashes and night sweats. However, patients may also report vaginal dryness, dyspareunia, arthralgias, and sleep disturbances.
These symptoms, the authors noted, can have a significant impact on quality of life.
The guideline outlines a “full spectrum” of treatment options for the most common symptoms, and choice of therapy is guided by several factors: safety, efficacy, symptom severity, age, medical history, patient preference, and an estimation of the benefit/risk ratio.1
“An accepted philosophy is that a fully informed patient should be empowered to make a decision that best balances individual [quality-of-life] benefits against potential health risks,” they wrote.
The guidelines has 5 main sections. The first provides guidelines on the clinical critera for diagnosing menopause, including defining the new term genitourinary syndrome of menopause. Genitourinary syndrome of menopause is a combination of vulvovaginal atrophy and urinary tract dysfunction.
The second section focuses on health considerations of all menopausal women such as addressing smoking cessation, alcohol use, cancer screening, cardiovascular risk, and bone health. Regardless of menopausal systems, this is a time where future well-being can be addressed, the authors explained.
The third section addresses the use of estrogen and progestogen therapy for menopausal symtoms. They provide a step-by-step guide on how to approach a patient considering menopausal HT.
“For menopausal women <60 years of age or <10 years past menopause with bothersome [vasomotor symptoms] (with or without additional climacteric symptoms) who do not have contraindications or excess cardiovascular or breast cancer risks and are willing to take [menopausal HT], we suggest initiating [estrogen therapy] for those without a uterus and [estrogen plus progestogen therapy] for those with a uterus,” the task force wrote.
Although menopausal hormone therapy (HT) has been an effective treatment for vaginal and vasomotor symptoms, its use declined after results from the Women’s Health Initiative (WHI) linked the therapy with various health risks for postmenopausal women, according to information in the guideline.1
“We do suggest hormone therapy for relief of menopausal symptoms for appropriately selected patients. We feel that in the years following the WHI, … the baby was tossed out with the bath water. And we feel that many clinicians have been hesitant to prescribe HT. The data that we present in our guideline help substantiate why we think, for carefully selected women, that this is a very reasonable approach,” Dr Stuenkel said during the press conference.
The authors noted that the most important consideration is the risk/benefit assessment and that quality of life factors may be important as well.
For women with contraindications, women at risk for breast cancer or cardiovascular disease, or women who are unwilling to take menopausal HT can consider nonhormonal options for relief of menopause symptoms.1
Nonhormonal therapies for vasomotor symptoms are addressed in the fourth section, including the evidence for lifestyle interventions and selective serotonin reuptake inhibitors (SSRIs)/serotonin and norepinephrine reuptake inhibitors (SNRIs) gabapentin, or pregabalin treatment.
For over-the-counter and alternative treatments for vasomotor symptoms, however, the guideline highlighted a lack of consistent evidence.1
The fifth section outlines treatment options for genitourinary syndrome of menopause with either vaginal moisturizers and lubricants or vaginal estrogen therapies.
“Hormones still work best for menopausal symptoms, but there are nonhormonal treatments that can be considered and new and interesting combinations of medications that may prove to be very effective,” Nanette Santoro, MD, professor and E. Stewart Taylor Chair of Obstetrics and Gynecology at the University of Colorado School of Medicine, said in an email interview with Endocrinology Advisor.
“There is concern in this field that younger physicians are afraid of hormone therapy and do not want to prescribe it for fear of doing harm,” she continued. “It’s critical to strike the right balance between symptom relief and its positive effects on quality of life and risk of hormones. This document will help clinicians navigate these decisions.”
The authors emphasized that gaps in knowledge about menopause symptoms still limit the ability to develop targeted therapies.
The authors report multiple disclosures.