Experts recommend assessing individual benefits, risks of menopausal therapies

The CPG, entitled "Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline," was published online and will appear in the November 2015 print issue of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society.

Menopause is the life stage that takes place when a woman's ovaries dramatically decrease production of the hormones estrogen and progesterone, and her menstrual periods stop. The average age of an American woman experiencing menopause is around 51 years old.

During menopause, many women experience symptoms such as hot flashes, night sweats, sleep disturbances, mood changes, joint pain, recurrent urinary tract infections, and difficult or painful sexual intercourse. These symptoms can start in the years before a woman's final menstrual period and last for more than a decade.

Women now have a broader range of treatment options for menopausal symptoms than ever before, but many clinicians are reluctant to pursue them. A 2012 Endocrine Society survey found that 72 percent of women currently experiencing menopause symptoms had not received any treatment for them.

Hormone therapy--at one time the most popular treatment for menopausal symptoms-- has been under intense scrutiny since 2002, when a large government study called the Women's Health Initiative (WHI) reported that hormone therapy -- specifically the combination of conjugated equine estrogens and medroxyprogesterone acetate (Prempro) -- increased the risk for blood clots, stroke, breast cancer and heart attacks in postmenopausal women aged 50 to 79 years at study onset. But additional research conducted in the ensuing years indicated the level of risk depends on the individual woman's health history, age and other factors. Experts have formed a consensus that the benefits of menopausal hormone therapy exceed the risks for most healthy women seeking relief of menopausal symptoms.

"There is no need for a woman to suffer from years of debilitating menopausal symptoms, as a number of therapies, both hormonal and non-hormonal are now available," said Cynthia A. Stuenkel, MD, the chair of the task force that authored the guideline and an endocrinologist specializing in menopause at the University of California, San Diego. "Every woman should be full partners with her health care providers in choosing whether treatment is right for her and what treatment option best suits her needs. The decision should be based on available evidence regarding the treatment's safety and effectiveness, as well as her individual risk profile and personal preferences."

In the CPG, the Endocrine Society recommends that women with a uterus who decide to undergo menopausal hormone therapy with estrogen and progestogen be informed about risks and benefits, including the possible increased risk of breast cancer during and after discontinuing treatment. Health care providers should advise all women, including those taking menopausal hormone therapy, to follow guidelines for breast cancer screening.

Other recommendations from the CPG include:

• Transdermal estrogen therapy by patch, gel or spray is recommended for women who request menopausal hormone therapy and have an increased risk of venous thromboembolism -- a disease that includes deep vein thrombosis.
• Progestogen treatment prevents uterine cancer in women taking estrogen for hot flash relief. For women who have undergone a hysterectomy, it is not necessary.
• If a woman on menopausal hormone therapy experiences persistent unscheduled vaginal bleeding, she should be evaluated to rule out endometrial cancer or hyperplasia.
• Medications called selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin or pregabalin are recommended for women who want medication to manage moderate to severe hot flashes, but either prefer not to take hormone therapy or have significant risk factors that make hormone therapy inadvisable.
• Low-dose vaginal estrogen therapy is recommended to treat women for genitourinary symptoms of menopause, such as burning and irritation of the genitalia, dryness, discomfort or pain with intercourse; and urinary urgency or recurrent infections. This treatment should only be used in women without a history of estrogen-dependent cancers.