Managing Menopause – SOGC 2014 Guideline

Assess Risk Factors:

1. Waist Circumference >=88cm / 35in ↑ DM, heart dz, HTN
2. Smoking
3. HTN (BP >140/90)
4. Past pregnancy complication  ↑ premature CV dz and death
   • preeclampsia, Gestation HTN, GDM
   • placenta abruption, idiopathic preterm delivery, fetal growth restrictions
5. Venous thromboembolism risks:
   • Factor V Leiden
   • Hx of DVT / PE
   • ↑ age and obesity
6. Stroke Risks
   • Obesity, HTN, dyslipidemia
   • DM, smoking

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Screenings:

1. Lipid profile screening – for >=50yo or postmenopausal women with risk factors
2. Framingham Risk Score Q3-5y for women 50-75yo
3. cardiovascular screening if + past pregnancy complications

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Vasomotor symptoms

1. Lifestyle modification
   • Reducing core body temperature, regular exercise, weight management, smoking cessation
   • Avoid known triggers, eg. hot drinks, EtOH
2. Offer hormone therapy
   • Most effective:  estrogen or E+P
   • Periodically review the risks (duration of use ↑ breast ca – ↓ to baseline after d/c HT) & benefits
   • Ok for women at increased risk of breast cancer w/ appropriate counselling & surveillance
     • discuss the uncertainty of risks with hormone Tx with breast ca dx
   • Add Progestogen to E & monitor adherence if women have an intact uterus
     • Either Cyclic (at least 12 days per month) or continuous progestogen therapy
   • Hormone therapy (estrogen) for women with 1) premature ovarian failure, 2) early menopause, 3) women who have undergone surgical menopause for Tx endometriosis, and use until the natural age of menopause
   • Alt: Rx progestins alone or low-dose OCP during menopausal transition
3. Non-hormonal Rx for hot flushes
   1. antidepresant, gabapentin, clonidine 
4. Don’t recommend complementary and alternative Tx for hot flushes due to limited safety data and evidence
   • May offer identified complementary / alternative Tx with demonstrated efficacy for mild menopausal symptoms.

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Urogenital Health

Vulvovaginal atrophy (50% within 3yr of menopause) should be addressed in all middle-aged women who complain of sexual dysfunction / pain.

1. Vaginal Atrophy (50% in 3yr of menopause) / Vulvovaginal atrophy
   • Address in all middle-aged women c/o sexual dysfunction or pain
   • Breast Ca pt – Aromatase inhibitors worse than tamoxifen
   • Tx with vaginal estrogen therapy (maintain vaginal & vulvar health)
     • Conjugated estrogen cream
     • intravaginal sustained-release estradiol ring
     • low-dose estradiol vaginal tab 
     • Alt: vaginal dilators, lubricants, moisturizers
     • Minimal system absorption, not contraindicated in women w/ systemic E therapy contraindications
       • Recent stroke and thromboembolic dz
       • Insufficient data in women with breast cancer who are receiving aromatase inhibitors
     • Routine progestin co-therapy is not required for endometrial protection
2. Postmenopausal urge / stress urinary incontinence
   • Systemic estrogen Tx not recommended
   • Vaginal estrogen can be recommended, particularly for urge incontinence
   • stress incontinence (non-Sx options)
     • Wt loss in obese women,
     • Behavioural modification
     • pelvic floor physiotherapy with or w/o biofeedback,
     • functional electrical stimulation
     • intravaginal pessaries, weighted vaginal cones
   • Urge incontinence
     • Behavioural modification
     • functional electrical stimulation
     • antimuscarinic Tx
3.  Dyspareunia
   • vaginal lubricants may be recommended
4. Recurrent UTI in postmenopausal women
   • Vaginal estrogen Tx recommended

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Ongoing management of the menopausal woman

1. Any unexpected vaginal bleeding after 12 months of amenorrhea is postmenopausal bleeding & should be investigated
2. Female sexual dysfunction (central + peripheral mechanisms, affected by T & E) can be categorized into desire (most common in mid-life women), arousal, pain, orgasm problems. Common in depressed pt and pt on SSRI.
   • A brief sexual history is part of the evaluation of the menopausal woman.
   • Interventions should be undertaken only if the patient is distressed about the problem.
   • Testosterone level – not useful & should not be used for the assessment / Dx of female sexual dysfunction
   • Tx –  address medical, psychological, & relationship issues (multifaceted)
   • Transdermal testosterone ↑ desire, arousal, and frequency of satisfactory sexual events & ↓ personal distress for women with surgical / natural menopause.
     • No approved products Tx female dysfunction in Canada