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Menopause

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Updated 2024 BGCS/BMS guidelines for the management of menopausal symptoms after treatment of gynecological cancer.

Background

Overview

Definition
Menopause is defined as the natural biological process in women that signifies the permanent end of menstruation and fertility.
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Pathophysiology
The pathophysiology of menopause is primarily related to the depletion of ovarian follicles, which leads to decreased production of the hormones estrogen and progesterone. This hormonal change triggers the various symptoms associated with menopause.
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Epidemiology
The prevalence of menopause-related vasomotor symptoms differs across geographic regions: estimated at 46% in North America, 45-69% in Latin America, 74% in Europe, and 22-63% in Asia.
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Risk factors
Several risk factors are associated with more severe menopausal symptoms. These include a history of depression, certain lifestyle factors such as smoking and obesity, and undergoing premature or surgical menopause.
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Disease course
Menopause is characterized by a variety of clinical manifestations. The most common symptoms include vasomotor symptoms such as hot flashes and night sweats, genitourinary symptoms like vaginal dryness and dyspareunia, and mood changes.
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Prognosis and risk of recurrence
The prognosis of menopause is generally favorable, the symptoms eventually subside without intervention.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of menopause are prepared by our editorial team based on guidelines from the British Menopause Society (BMS/BGCS 2024), the Canadian Urological Association (CUA 2024), the American Society of Hematology (ASH 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021,2017,2014), the Endocrine Society (ES 2020,2015), the American College of Obstetricians ...
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Screening and diagnosis

Diagnostic criteria
As per ES 2015 guidelines:
Consider diagnosing menopause based on the clinical criteria of the menstrual cycle.
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Consider making a presumptive diagnosis of menopause based on the presence of vasomotor symptoms and, when indicated, laboratory testing (FSH and serum estradiol), if establishing a diagnosis of menopause is necessary in females having undergone a hysterectomy without bilateral oophorectomy or presenting with a menstrual history inadequate to ascertain menopausal status.
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Diagnostic investigations

Evaluation of vulvovaginal atrophy: as per SOGC 2021 guidelines, obtain comprehensive screening for genitourinary syndrome of menopause symptoms on an ongoing basis in menopausal females, as symptoms can present insidiously and become bothersome long after the menopausal transition.
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  • Evaluation of sexual dysfunction

  • Evaluation of vaginal bleeding

  • Cardiovascular risk assessment

  • Evaluation before hormone therapy

Medical management

Management of vasomotor symptoms, hormonal therapy: as per SOGC 2021 guidelines, initiate menopausal hormone therapy as the most effective treatment for menopausal symptoms.
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  • Management of vasomotor symptoms (tibolone)

  • Management of vasomotor symptoms (non-hormonal therapy)

  • Considerations for hormone therapy

  • Management of vulvovaginal atrophy (lubricants and moisturizers)

  • Management of vulvovaginal atrophy (local estrogen therapy)

  • Management of vulvovaginal atrophy (systemic estrogen therapy)

  • Management of vulvovaginal atrophy (vaginal laser therapy)

  • Management of sexual dysfunction

  • Management of urinary incontinence

  • Management of recurrent UTI

  • Management of cardiovascular risks

  • Management of osteoporosis

  • Management of cognitive symptoms

  • Management of depression

  • Management of sleep disorders

Nonpharmacologic interventions

Lifestyle modifications: as per ES 2015 guidelines, consider advising the following nonpharmacologic measures in postmenopausal patients with mild or less bothersome hot flashes:
turning down the thermostat
dressing in layers
avoiding alcohol and spicy foods
reducing obesity and stress.
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  • Smoking cessation

  • Alternative medicine

Specific circumstances

Patients with early menopause: as per SOGC 2021 guidelines, consider initiating hormone replacement therapy in patients with loss of ovarian function or with decreased ovarian function before the age of 45 years, continued until the average age of menopause.
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  • Patients at increased risk of gynecological cancers

  • Patients with ovarian cancer

  • Patients with endometrial cancer

  • Patients with uterine sarcoma

  • Patients with cervical or vaginal cancer

  • Patients with vulvar cancer

  • Patients with breast cancer

  • Patients with hormone-independent cancer

Patient education

General counseling: as per SOGC 2021 guidelines, educate females entering menopause about the progressive impact of estrogen deficiency on urogenital health and the many options available for symptom relief.
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