Last updated January 18, 2022

Diagnosis and Treatment of Menopause

RECOMMENDATIONS

Menopausal hormone therapy (MHT) may be appropriate for the relief of severe menopausal symptoms in selected postmenopausal women, on the basis of an individually determined benefit-versus-risk profile. (I, A)
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MHT may be prescribed during the perimenopause and early menopause for relief of menopausal symptoms and treatment of vulvovaginal atrophy. (I, A)
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The use of the transdermal route of estrogen administration should be considered in order to avoid the hepatic “first-pass effect,” which may theoretically reduce the risk of thromboembolic disease. (III, B)
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The use of transvaginal estrogen may be considered to provide topical effects with less systemic absorption. (III, B)
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The dose of MHT may be reduced with advancing age. (III, C)
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Because of the increased risk of endometrial cancer, unopposed estrogen should not be used in women with an intact uterus. (I, D)
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Progestational agents should be used for a minimum of 10 to 14 days per month in women treated with estrogen who have an intact uterus. (I, A)
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Long-cycle therapy with use of a progestagen for 14 days every 3 months may be considered, in an effort to reduce breast exposure to progestagens, despite lack of definitive assessment of efficacy. (II, B)
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Amenorrhea may be achieved by using a low dose of a progestagen administered continuously (daily) in conjunction with estrogen. Because recent studies suggest adverse breast outcomes with continuous progesterone exposure, this form of therapy is not recommended. (II, D)
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MHT should be used in the lowest dose and for the shortest period necessary to control menopausal symptoms. (I, A)
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Therapeutic trials of nonhormonal prescription medications, including clonidine, antidepressants (selective serotonin reuptake inhibitors), and gabapentin, may be considered for the relief of menopausal symptoms in women with no specific contraindications. (II, B)
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Over-the-counter supplements should be used with caution because they are not regulated by the US Food and Drug Administration (FDA) and have the potential for interactions with drugs and for causing harm. (II, C)
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Phytoestrogens, including soy-derived isoflavonoids, result in inconsistent relief of symptoms. Because these compounds may have estrogenic effects, women with a personal or strong family history of hormone-dependent cancers (breast, uterine, or ovarian), thromboembolic events, or cardiovascular events should not use soy-based therapies. (I, D)
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Custom compounded “bioidentical hormone therapy” is not recommended. (I, D)
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FDA-approved bioidentical hormone preparations may be considered, but evidence is lacking that they are safer or more effective than traditional forms of hormone therapy. (II, C)
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MHT should be used for the prevention and treatment of osteoporosis within the context of the overall benefit-versus-risk analysis of each patient. Data from multiple randomized controlled trials (RCTs) substantiate the efficacy of estrogens in preserving bone mass and, less consistently, preventing fractures, but nonhormonal therapeutic options for bone health exist. (I, A)
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Hormone therapy for the prevention or treatment (or both) of dementia is not recommended. (I, D)
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MHT should be prescribed to women in conjunction with a thorough discussion of the possible relationship of MHT to breast cancer. Current evidence suggests that E+P regimens are associated with a possible higher risk of breast cancer than is therapy with estrogen alone. (I, A)
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Concordant with current FDA warnings, we recommend that women who are at increased risk of thromboembolic disease should not take estrogen-containing therapy (although there is evidence that transdermal estradiol may not increase this risk; see subsequent material). (I, D)
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Women should be advised that smoking increases the risk of cardiovascular and venous thromboembolic disease when taking estrogen, and aggressive smoking cessation programs should be advised. (I, A)
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MHT is not recommended for primary or secondary prevention of cardiovascular disease. (I, D)
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Lipid profiles, smoking history, and diabetes history as well as family history should be assessed to assist in the determination of individual cardiovascular risk. (I, A)
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Women should be advised that cerebrovascular accidents occur with increased frequency in patients taking estrogen alone or E+P combination therapies in an age-dependent manner. (I, A)
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Women should be advised that there may be an increase in ovarian epithelial tumors with the use of estrogen for more than 10 years.

(II, B)
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Women may be advised that several studies including the Women’s Health Initiative (WHI) have demonstrated a lower risk of colon cancer in women treated with E+P combination. (II, B)
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Recommendation Grading

Overview

Title

Diagnosis and Treatment of Menopause

Authoring Organization

Publication Month/Year

November 1, 2011

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory

Scope

Diagnosis, Treatment

Diseases/Conditions (MeSH)

D008593 - Menopause

Keywords

menopause

Source Citation

Neil Goodman, Rhoda Cobin, Samara Ginzburg, Ira Katz, and Dwain Woode (2011) American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause. Endocrine Practice: November 2011, Vol. 17, No. Supplement 6, pp. 1-25.