Menopause: Don’t sweat it: Part 1

Please note: This is the first article in a planned two-part series on Menopause. Part 2 will outline more details on the management of menopause.

Authors

Kerstin Gustafson MD FRCSC (biography and disclosures) and Colleen Dy MD FRCS(C) NCMP (biography and disclosures)

Dr. Kerstin Gustafson’s disclosures: Received payments as honoraria for speaking on various medical topics, both from for-profit organizations and from non-profits such as the SOGC. Served on regional advisory boards for Amgen, Lilly, Pfizer, Bayer, Sanofi, and Novartis. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with clinical trial data and published practice guidelines.

Dr. Colleen Dy’s disclosures: I received payments as honoraria for speaking on various medical topics from Pfizer, Merck, Apotex, Knight, and BioSyentI. I served on regional advisory boards for Pfizer, Apotex, and Astellas. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with clinical trial data and published practice guidelines.

What we did before

Menopause is an expected consequence of aging. We will use the term ‘women’ to describe people experiencing menopause, while understanding that some people may identify differently. Despite menopause being a normal transition, it is often accompanied by significant bothersome symptoms. The most common are collectively termed vasomotor symptoms or VMS, including hot flushes and night sweats, but there have been over 30 distinct symptoms identified, including those affecting multiple domains of health, as shown in Table 1.

Table 1. Common menopausal symptoms

Menopause is defined as the final menstrual period, recognized after one year without a period. It may be difficult to diagnose in patients who use hormonal contraception or have had a hysterectomy, but occurs on average at age 51 in North America. About 85% of women experience at least one symptom around the time of menopause.¹ Symptoms of menopause can last for an average of 7.4 years, with some women experiencing symptoms lasting decades.² Given that there are nearly 710,000 women aged 45-64 in British Columbia, hundreds of thousands of women are symptomatic at any given time.³

Menopausal symptoms are bothersome for many women, and can lead to a reduction in quality of life and work ability that is parallel to the degree of symptomatology.⁴ Women make up around 50% of the workforce in Canada, around half of whom are women in their menopausal years.⁵ About 10% of women leave the workforce completely due to menopausal symptoms, and there are many others who do not reach their full potential.^5,6

Women often seek medical care around the time of menopause, giving us an opportunity to engage them at a time of increasing risk for significant diseases, such as cardiovascular, metabolic, bone and breast. However, in one survey, only 27% of Canadian women reported that their family physician proactively discussed menopause with them.⁷ Eventually, 41% sought out advice from their family physician, but 72% of those women felt that they received unhelpful advice from their clinician.⁷

The root of this care gap, which is global, is thought to be the paucity of education that medical professionals have received regarding menopause in the last 20 years.^8-10 This largely stems from the fear generated by the Women’s Health Initiative (WHI) in 2002.¹¹ In a 2019 study of medical residents⁹, most felt ill equipped to manage menopausal complaints, feeling they had not received adequate education or training on managing menopause. Throughout North America, menopause education is rarely part of the formal training program for obstetrician gynecologists, who are often presumed to be specialists in this area.¹²

A generation of physicians was taught that ‘hormone replacement’ was safe for most women and it was even recommended for disease prevention.¹³ Following the 2002 publication of the WHI, the subsequent generation was taught to fear menopausal hormone therapy (MHT), which is the current preferred term, due to messaging that it caused a significantly increased risk of breast cancer, heart disease and stroke.

Since then, we have learned that the reality, as in so many cases, lies somewhere in the middle. A concise critical analysis of the WHI can be found in the 2017 Climacteric article titled ‘The evidence base for HRT: What can we believe?’¹⁴  The conclusion of this article is consistent with the current Menopause Society position on MHT which states that “for women aged younger than 60 or who are within 10 years of menopause and have no contraindications, the benefit-risk ratio is favorable for treatment of bothersome VMS and prevention of bone loss.”¹⁵ It also states that “longer durations of therapy should be for documented indications such as persistent VMS, with shared decision-making and periodic reevaluation.”¹⁵

Along with a lack of training on the topic of menopause, there are other factors that can lead to hesitance in prescribing medications for management of menopausal symptoms. One factor includes misunderstanding of the contraindications to MHT, shown in Table 2, which are fewer than those for combined hormonal contraception (CHC). The reason for the lower risk is multifactorial, but includes that the estrogens used in MHT are less thrombogenic than the ethinyl estradiol (EE) most often found in CHCs, as well as the much lower doses of hormones used in MHT. This article is focusing on systemic hormone therapy, rather than local vaginal estrogen, which is safe for most women and is discussed in our previous TCMP article, ‘Genitourinary syndrome of menopause (GSM) — a refresher’.

Table 2. Contraindications to MHT¹⁹

What changed our practice

Despite the paucity of formal education in our training, happily, there are an increasing number of clinical resources to help guide us and to increase our confidence.^17-19

The most user-friendly tool currently available for deciding on treatment is the Menopause Quick 6 (MQ6). This practical Canadian tool and accompanying website offers information for both clinicians and patients, and includes an interactive treatment algorithm for physicians which helps to take uncertainty out of decision making.¹⁹

A recent article in the Canadian Medical Association Journal (CMAJ) titled ‘A pragmatic approach to the management of menopause’¹⁶ provides a concise narrative summary of the main issues surrounding menopause and considerations that need to be taken when managing patients. This includes a list of preparations currently available in Canada. A 2022 summary article in the British Columbia Medical Journal (BCMJ) titled ‘Managing Menopause’^17,18 includes a section specifically on managing vasomotor symptoms, as well as a section focusing on hormone therapy and breast cancer, cardiovascular disease and premature ovarian insufficiency. This also includes a list of currently available preparations.

Physicians can now offer patients a balanced evidence based opinion on the risks and benefits of MHT, for the benefit of our symptomatic patients. As well, there are a number of products, both hormonal and non-hormonal, that offer distinct safety profiles that can help us tailor management to the patient.^15,20 For example, some preparations of hormones have less impact on breast density, and some carry a lower risk of venous thromboembolism (VTE). Newer non-hormonal treatments targeting the neurons in the brain that cause hot flushes are now available, including fezolinenant²¹—recently approved by Health Canada—and elinzanetant which is pending approval.²²

What we do now

Now, we try to include at least one question about menopausal symptoms proactively in our seemingly asymptomatic patients over the age of 40. This can be as simple as asking if they have any hot flushes. For patients who deny having any symptoms currently, we direct them to the menopause websites of The Canadian Menopause Society, The Menopause Society and The Society of Obstetrician and Gynecologists of Canada (SOGC) , so that they can become informed about what to expect in the upcoming years from evidence-based sources. Patients can also download a symptom tracker from the Menopause Foundation of Canada.

For symptomatic patients, after taking a medical history, we review menopausal symptoms and available treatments—both hormonal and non-hormonal—including a discussion on lifestyle modifications. We include general counseling on exercise (recommending 150 minutes per week, and twice weekly resistance activities).²³ We promote cardiovascular health, adequate calcium and Vitamin D intake, and modification of lifestyle risks for breast, colon and lung cancer, and recommend routine screening for HPV, mammography and colon cancer screening.²⁴ This may be done in one or more visits.

If the patient would like to consider hormone therapy, we can use the MQ6 algorithm to help decide if they are a good candidate and, if so, which route and types of preparation are most suitable. Using the algorithm helps standardize our practice and decreases uncertainty. As we become more confident in our own practice, we can start to close the care gap by teaching the next generation of healthcare providers about guiding patients through this important life event.

Resources

1. Menopause Quick 6 (MQ6) algorithm
2. The Canadian Menopause Society
3. The Menopause Society
4. The Society of Obstetrician and Gynecologists of Canada (SOGC)
5. A pragmatic approach to the management of menopause – CMAJ
6. Managing Menopause: VMS – BCMJ
7. Managing Menopause: MHT and breast, CVD and POI – BCMJ
8. Menopause Symptom Tracker – Menopause Foundation of Canada

References

1. Woods NF, Mitchell ES. Symptoms during the perimenopause: prevalence, severity, trajectory, and significance in women’s lives. Am J Med. 2005;118(12B Suppl):12-24.
   doi:10.1016/j.amjmed.2005.09.031 (View)
2. Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539. doi:10.1001/jamainternmed.2014.8063 (View)
3. Statista Research Department. Population estimate of British Columbia, Canada in 2023, by age and sex. Published July 4, 2024. Accessed May 5, 2024. (View)
4. Whiteley J, DiBonaventura MD, Wagner JS, Alvir J, Shah S. The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. J Womens Health (Larchmt). 2013;22(11):983-990. doi:10.1089/jwh.2012.3719 (View)
5. Menopause Foundation of Canada. Menopause and work in Canada. Published October 16, 2023. Accessed December 19, 2024. (View)
6. Cronin C, Abbott J, Asiamah N, Smyth S. Menopause at work-an organisation-based case study. Nurs Open. 2024;11(1):e2058. doi:10.1002/nop2.2058 (View)
7. Menopause Foundation of Canada. MFC report: the silence and the stigma: menopause in Canada. Published October 6, 2022. Accessed May 5, 2024. (View)
8. Barber K, Charles A. Barriers to accessing effective treatment and support for menopausal symptoms: a qualitative study capturing the behaviors, beliefs, and experiences of key stakeholders. Patient Prefer Adherence. 2023;17:2971-2980. doi:10.2147/PPA.S430203 (View)
9. Kling JM, MacLaughlin KL, Schnatz PF, et al. Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey. Mayo Clin Proc. 2019;94(2):242-253. doi:10.1016/j.mayocp.2018.08.033 (View with UBC)
10. Armeni E, N. M. Menopause medical education around the world: the way forward to serve women’s health. Curr Opin Endocrinol Metab Res. 2022;100387. doi:10.1016/j.coemr.2022.100387 (View with UBC)
11. Black D. Menopause hormone therapy: 2023 update. Can Prim Care Today. 2023;1(3):17-21. (View)
12. Allen JT, Laks S, Zahler-Miller C, et al. Needs assessment of menopause education in United States obstetrics and gynecology residency training programs. Menopause. 2023;30(10):1002-1005. doi:10.1097/GME.0000000000002234 (View with UBC)
13. American College of Physicians. Guidelines for counseling postmenopausal women about preventive hormone therapy. Ann Intern Med. 1992;117:1038-1041. doi:10.7326/0003-4819-117-12-1038 (View with UBC)
14. Langer RD. The evidence base for HRT: what can we believe? Climacteric. 2017;20(2):91-96. doi:10.1080/13697137.2017.1280251 (View with UBC)
15. The North American Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/gme.0000000000002028 (View with UBC)
16. Lega IC, Fine A, Antoniades ML, Jacobson M. A pragmatic approach to the management of menopause. CMAJ. 2023;195(19):E677-E672. doi:10.1503/cmaj.221438 (View)
17. Jina R, Rowe TC, Dunne C. Managing menopause part 1: vasomotor symptoms. BCMJ. 2022;64(8):344-349. (View)
18. Jina R, Rowe TC, Dunne C. Managing menopause part 2: hormone therapy and breast cancer, cardiovascular disease, and premature ovarian insufficiency. BCMJ. 2022;64(8):350-353. (View)
19. Goldstein S. An efficient tool for the primary care management of menopause. Can Fam Physician. 2017;63(4):295-298. (View)
20. The North American Menopause Society. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590. doi:10.1097/GME.0000000000002200 (View with UBC)
21. Lederman S, Ottery FD, Cano A, et al. Fezolinetant for treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): a phase 3 randomised controlled study. Lancet. 2023;401(10382):1091-1102. doi:10.1016/S0140-6736(23)00085-5 (View with UBC)
22. Pinkerton .JV, Simon JA, Joffe H, et al. Elinzanetant for the Treatment of Vasomotor Symptoms Associated With Menopause: OASIS 1 and 2 Randomized Clinical Trials. JAMA. 2024;332(16):1343–1354. doi:10.1001/jama.2024.14618). (View)
23. Public Health Agency of Canada. Physical activity tips for adults 18-64 years. Published October 1, 2018. Accessed July 28, 2024. (View)
24. HealthLink BC. Health screening: finding health problems early. Accessed September 28, 2024. (View)

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Menopause: Don’t sweat it: Part 1

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