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Management of the menopause (C-Gyn 9)

College Statement
C-Gyn 9
1st Endorsed: March 1995
Current: November 2011
Review: July 2014

 

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges the contribution of the Australasian Menopause Society (AMS) in the compilation and continuous review of this statement.

The menopause is a significant reproductive life stage for women and may have other implications for emotional, metabolic and cardiovascular health as well as quality of life. Menopause may be physiological, pathological or iatrogenic. It is incumbent upon fellows and members of RANZCOG to ensure awareness of these changes are promoted amongst the medical profession and the wider general community.

 

  1. The menopause refers to the final menstrual period. A woman is postmenopausal 12 months after her final menstrual period. The menopause transition is the time from the onset of menopausal symptoms (commonly vasomotor symptoms or irregular menstrual bleeding) until the post menopause1. The menopause transition commonly starts around 47 years and the average age of natural menopause is 51 years. Smokers may have an earlier menopause2.
  2. Vasomotor symptoms (VMS) are the most common reason for women to seek advice and treatment at menopause. Symptoms commonly start during the menopause transition with an average duration of 4-5 years. In around 10% of women symptoms may persist for more than a decade3. Women may report a broad range of physical and psychological symptoms at menopause. However, the key symptoms likely to improve with HRT include vasomotor symptoms, vaginal dryness, sleep disturbance and joint symptoms4,5.
  3. Midlife women should be offered information and advice about normal menopausal changes and symptoms and, if required, individualised discussion of management options for troublesome symptoms. This consultation may also be an opportunity for midlife health assessment. Current national breast and cervical screening guidelines should be followed. Fracture risk can be calculated using an online tool such as FRAX (http://www.shef.ac.uk/FRAX) and bone density can be measured using Dual X-ray Absorptiometry (DXA) for those at increased fracture risk.
  4. Bone density should be measured using DXA in those at increased risk of fracture (www.osteoporosis.org.au/health-professionals/general-practitioners/). Measurement of cardiovascular markers should be guided by age and risk factors (http://www.heartfoundation.org.au/SiteCollectionDocuments/aust-cardiovascular-risk-charts.pdf)
  5. Symptoms of anxiety and depression are common in women and may be increased during the menopause transition, particularly in those experiencing troublesome vasomotor symptoms. Menopause may be a time of vulnerability for the development of clinical anxiety and or depressive disorders. Women with a history of affective disorders and those with premature/surgical menopause or following a cancer diagnosis may be at greater risk. Consider mental health referral in those with symptoms   of mood disorder6.
  6. Women seeking relief from menopausal symptoms should first be offered advice on life style changes including stress reduction, regular exercise, optimal weight management, appropriate diet and avoidance of smoking and excessive alcohol and caffeine intake should also be addressed. Recent high quality evidence suggests that mindfulness training and cognitive behaviour therapy may reduce both the impact and severity of vasomotor symptoms7.
  7. The principal indication for using HRT is the relief of menopausal symptoms. The decision to start and to continue HRT will depend on the nature and severity of menopausal symptoms, their impact on function and the individual health profile of the woman. Dose is generally titrated to symptom relief and side effects, but most clinical guidelines advise starting with low dose therapy and review at least annually5. There are no fixed guidelines on duration of use. HRT should be avoided in women with pre-existing cardiovascular and cerebrovascular disease, previous history of venous thromboembolism (VTE) or breast cancer. Use with caution in women with diabetes mellitus, history of endometrial cancer, active SLE, high cardiovascular risk and abnormal liver function. Abnormal bleeding should be investigated prior to starting HRT
  8. Women with premature (less than 40 years) or early (less than 45 years) menopause should be offered HRT at least until aged 50-51 years unless otherwise contraindicated. Menopausal symptoms may be more severe in younger women and sexual dysfunction may be a greater concern
  9. HRT should contain a progestogen for at least 10 days per month in women who retain their uterus to provide endometrial protection5. Unopposed estrogen increases the risk of endometrial cancer
  10. For women with vaginal symptoms only, local vaginal estrogen is the most effective therapy8. Non-hormonal vaginal moisturisers (eg Replens), acidic gels or silicone based lubricants may be also useful for vaginal dryness.
  11. HRT increases bone density and reduces fracture risk. Prevention or treatment of low bone density is not considered a primary indication for HRT use. However, HRT should be considered for symptomatic women who have reduced bone density but have not sustained a fracture.
  12. HRT has not been shown to be effective for primary or secondary prevention of cardiovascular disease and should not be given for this purpose. However, the use of HRT in healthy younger (age <59 years) symptomatic women does not appear to confer a significant increased risk of cardiovascular disease.
  13. HRT increases breast density and combined oestrogen-progestogen increases the risk of breast cancer, especially in women over 59 years. Whether oestrogen only HRT and breast cancer is controversial as the WHI oestrogen-only study showed no increase in breast cancer risk after seven years. Breast cancer risk increases with duration of HRT use. Whilst there is no optimum duration of HRT use for all women, annual review is recommended and cessation should be discussed after 4-5 years treatment.
  14. Oral HT use doubles the baseline risk of VTE in women of all age (RR 2.14 (1.64-2.81) and may be dose related10. Transdermal HRT may have a more favourable effect on VTE risk and may be a safer option in those at increased VTE risk (http://www.rcog.org.uk/). Thromboembolic risk with HRT is additive to other established risk factors such as obesity and smoking. Previous history of VTE is a contraindication to HRT use.  Oral HRT increases the risk of stroke and this effect is independent of years since menopause11. It is unclear whether transdermal HRT increases stroke risk.
  15. Cessation of HRT may lead to a recurrence of VMS in around 50% of women. There is no clear evidence on the optimum method of discontinuing HRT.
  16. Non-hormonal therapies may be effective for VMS. Agents shown to be superior to placebo in randomised controlled trials include gabapentin, venlafaxine, desvenlafaxine, paroxetine, fluoxetine, citalopram and escitalopram; however, these are short term trials and long term efficacy and safety data is lacking12. Paroxetine and fluoxetine should not be used in women taking tamoxifen as they may interfere with tamoxifen metabolism13. It is not yet known whether this impacts on breast cancer recurrence.
  17. Over the counter complementary/ alternative medications, such as black cohosh and phytoestrogens, have not consistently been shown to be effective for VMS. Improvement of VMS has been demonstrated in studies of mindfulness training and cognitive behavioural  therapy7.
  18. Tibolone, a synthetic steroid with oestrogenic, progestogenic and weak androgenic effects, is also effective for vasomotor and urogenital symptoms14. Tibolone should only be used in women > 12 months since menopause as it may cause irregular bleeding in younger women. Tibolone also increases bone density and reduces fracture risk. The risk of breast cancer with tibolone is unknown. Tibolone may increase the risk of stroke in older women >65 years15.

 

References

  1. Soules MR, Sherman, S., Parrott, E., Rebar, R., Santoro, N., Utian, W., Woods, N. Executive summary: Stages of Reproductive Aging Workshop (STRAW). Fertil Steril 2001;76:874-8.
  2. Politi MC, Schleinitz, M.D., Col, N.F. Revisiting the duration of vasomotor symptoms of menopause: a meta-analysis. J Gen Intern Med 2008;23:1507-13.
  3. Maki PM, Freeman, E.W., Greendale, G.A., Henderson, V.W., Newhouse, P.A., Schmidt, P.J., Scott, N.F., Shively, C.A., Soares, C.N. Summary of the National Institute on Aging-sponsored conference on depressive symptoms and cognitive complaints in the menopausal transition. Menopause 2010;17:815-22.
  4. Sturdee DW, Pines, A. Updated IMS recommendations on postmenopausal hormone therapy and preventive strategies for midlife health. Climacteric 2011;14:302-20.
  5. MacLennan AH, Lester S, Moore V. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database of Systematic Reviews 2004;18::CD002978.
  6. Welton AJ, Vickers, M.R., Kim ,J,. Ford, D., Lawton, B.A., MacLennan, A.H., Meredith, S.K., Martin, J., Meade, T.W.; WISDOM team. Health related quality of life after combined hormone replacement therapy: randomised controlled trial.BMJ 2008;337:1190.
  7. Suckling J, . Lethaby, A,. Kennedy, R. Local oestrogen for vaginal atrophy in postmenopausal women (review). In: Collaboration TC, ed. The Cochrane Library. Vol. 2007: Wiley, 2007.
  8. Loprinzi CL, Sloan, J., Stearns, V., Slack, R., Iyengar, M., Diekmann, B., Kimmick, G., Lovato, J., Gordon, P., Pandya, K., Guttuso, T. Jr, Barton, D., Novotny, P. Newer antidepressants and gabapentin for hot flashes: an individual patient pooled analysis. J Clin Oncol 2009;27:2831-7.
  9. Rossouw JE, Anderson, G.L., Prentice, R.L., LaCroix, A.Z., Kooperberg, C., Stefanick, M.L., Jackson, R.D., Beresford, S.A., Howard, B.V., Johnson, K.C., Kotchen, J.M., Ockene, J.; Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321-33.
  10. Canonico M, Oger, E., Plu-Bureau, G., Conard, J., Meyer, G., Lévesque, H., Trillot, N., Barrellier, M.T., Wahl, D., Emmerich, J., Scarabin, P.Y.; Estrogen and Thromboembolism Risk (ESTHER) Study Group. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. Circulation 2007;113:840-5.
  11. Rossouw JE, Prentice, R.L., Manson, J.E., Wu, L., Barad, D., Barnabei, V.M., Ko, M., LaCroix, A.Z., Margolis, K.L., Stefanick, M.L. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA 2007;297:1465-77.
  12. Renoux C, Dell'aniello, S., Garbe, E., Suissa, S. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case-control study. BMJ 2010 340:doi: 10.1136/bmj.c2519.
  13. Hammar M, Christau S, Nathorst-Boos J, Rud T, Garre K. A double-blind, randomised trial comparing the effects of tibolone and continuous combined hormone replacement therapy in postmenopausal women with menopausal symptoms. British Journal of Obstetrics & Gynaecology 1998;105:904-11.
  14. Cummings SR, Ettinger, B., Delmas, P.D., Kenemans, P., Stathopoulos, V., Verweij, P., Mol-Arts, M., Kloosterboer, L., Mosca, L., Christiansen, C., Bilezikian, J., Kerzberg, E.M., Johnson, S., Zanchetta, J., Grobbee, D.E., Seifert, W., Eastell, R.; LIFT Trial Investigators. The effects of tibolone in older postmenopausal women. N Engl J Med 2008;359:697-708.
  15. Cummings SR, Ettinger, B., Delmas, P.D., Kenemans, P., Stathopoulos, V., Verweij, P., Mol-Arts, M., Kloosterboer, L., Mosca, L., Christiansen, C., Bilezikian, J., Kerzberg, E.M., Johnson, S., Zanchetta, J., Grobbee, D.E., Seifert, W., Eastell, R.; LIFT Trial Investigators. The effects of tibolone in older postmenopausal women. N Engl J Med. 2008;359(7):697-708

 

Links to other related College Statements

Management of the menopause after breast cancer (C-Gyn 15)

Guidelines for consent and the provision of information regarding proposed treatment (C-Gen 2)

 

Other Useful Links 

National Breast Screening Programme (Breastscreen Australia).
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/breastscreen-about

National Cervical Screening Programme (Australia).
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-aboutl

National Breast Screening Programme (New Zealand).
http://www.nsu.govt.nz/current-nsu-programmes/breastscreen-aotearoa.aspx

National Cervical Screening program (New Zealand).http://www.nsu.govt.nz/current-nsu-programmes/national-cervical-screening-programme.aspx

The risk of breast cancer with HRT use (Media release of the Australasian Menopause Society 2002). http://www.menopause.org.au/public/media_detail.asp?ID=25

Advice to members of the Australasian Menopause Society: Indications for Prescribing Oestrogens and Progestogens in Menopausal Women, Update September 2003.

http://www.menopause.org.au/public/media_detail.asp?ID=37

 

Patient Resources

RANZCOG Patient information pamphlet “Menopause: A guide for women” (released 2003).

Disclaimer

This College Statement is intended to provide general advice to Practitioners. The statement should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient.

The statement has been prepared having regard to general circumstances. It is the responsibility of each Practitioner to have regard to the particular circumstances of each case, and the application of this statement in each case. In particular, clinical management must always be responsive to the needs of the individual patient and the particular circumstances of each case.

This College statement has been prepared having regard to the information available at the time of its preparation, and each Practitioner must have regard to relevant information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material that may have become available after the date of the statements.

 
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