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Boneresearch.caSOGC CLINICAL PRACTICE GUIDELINE
No. 311, September 2014 (Replaces No. 222, January 2009) This clinical practice guideline has been prepared by the
The literature searches and bibliographic support for this Menopause and Osteoporosis Working Group, reviewed
guideline were undertaken by Becky Skidmore, Medical by the Clinical Practice Gynaecology and Family Physician
Research Analyst, Society of Obstetricians and Gynaecologists Advisory Committees, and approved by the Executive and
Council of the Society of Obstetricians and Gynaecologists
Claudio N . Soares, MD, PhD, Toronto ON Disclosure statements have been received from all contributors . PRINCIPAL AUTHORS
Robert Reid, MD, Kingston ON
Beth L . Abramson, MD, Toronto ON Objective: To provide updated guidelines for health care providers on
Jennifer Blake, MD, Toronto ON the management of menopause in asymptomatic healthy women Sophie Desindes, MD, Sherbrooke QC as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular Sylvie Dodin, MD, Quebec QC disease, breast cancer, urogynaecology, and sexuality .
Shawna Johnston, MD, Kingston ON Outcomes: Lifestyle interventions, prescription medications, and
Timothy Rowe, MB BS, Vancouver BC complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Namrita Sodhi, MD, Toronto ON Counselling and therapeutic strategies for sexuality concerns in Penny Wilks, ND, Dundas ON the peri- and postmenopausal years are reviewed . Approaches Wendy Wolfman, MD, Toronto ON to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline .
MENOPAUSE AND OSTEOPOROSIS WORKING GROUP
Evidence: Published literature was retrieved through searches of
Michel Fortier, MD (Co-Chair), Quebec QC PubMed and The Cochrane Library in August and September Robert Reid, MD (Co-Chair), Kingston ON 2012 with the use of appropriate controlled vocabulary (e .g ., Beth L . Abramson, MD, Toronto ON hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e .g ., hormone therapy, Jennifer Blake, MD, Toronto ON perimenopause, heart disease, and sexuality) . Results Sophie Desindes, MD, Sherbrooke QC were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and Sylvie Dodin, MD, Quebec QC observational studies . Results were limited to publication dates Lisa Graves, MD, Toronto ON of 2009 onwards and to material in English or French . Searches were updated on a regular basis and incorporated in the guideline Bing Guthrie, MD, Yellowknife NT until January 5, 2013. Grey (unpublished) literature was identified Aliya Khan, MD, Hamilton ON through searching the websites of health technology assessment and health technology assessment-related agencies, national Shawna Johnston, MD, Kingston ON and international medical specialty societies, and clinical practice Timothy Rowe, MB BS, Vancouver BC guideline collections . Namrita Sodhi, MD, Toronto ONPenny Wilks, ND, Dundas ON Key Words: Menopause, estrogen, vasomotor symptoms,
Wendy Wolfman, MD, Toronto ON urogenital symptoms, mood, memory, cardiovascular diseases, breast cancer, lifestyle, nutrition, exercise, estrogen therapy, complementary therapies, progestin, androgen, menopausal hormone therapy, hormones, estrogen, testosterone, menopause, depression, antidepressants, sexuality J Obstet Gynaecol Can 2014;36(9):830–833
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information
should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate
amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be
reproduced in any form without prior written permission of the SOGC.
830 l SEPTEMBER JOGC SEPTEMBRE 2014
SOGC CLINICAL PRACTICE GUIDELINE
Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on
Preventive Health Care
Quality of evidence assessment*
Classification of recommendations† I: Evidence obtained from at least one properly randomized A . There is good evidence to recommend the clinical preventive action II-1: Evidence from well-designed controlled trials without B . There is fair evidence to recommend the clinical preventive action II-2: Evidence from well-designed cohort (prospective or C. The existing evidence is conflicting and does not allow to make a retrospective) or case–control studies, preferably from recommendation for or against use of the clinical preventive action; more than one centre or research group however, other factors may influence decision-making II-3: Evidence obtained from comparisons between times or D . There is fair evidence to recommend against the clinical preventive action places with or without the intervention . Dramatic results in uncontrolled experiments (such as the results of treatment with E . There is good evidence to recommend against the clinical preventive penicillin in the 1940s) could also be included in this category III: Opinions of respected authorities, based on clinical experience, L. There is insufficient evidence (in quantity or quality) to make descriptive studies, or reports of expert committees a recommendation; however, other factors may influence *The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care .
†Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care .
Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W . Canadian Task Force on Preventive Health Care . New grades for recommendations from the Canadian Task Force on Preventive Health Care . CMAJ 2003;169:207–8 .
Values: The quality of the evidence in this document was rated using
3 . Blood pressure should be assessed and controlled as women go the criteria described by the Report of the Canadian Task Force on through menopause. (II-2B) If the systolic blood pressure is ≥ 140 Preventive Health Care (Table) .
mmHg and/or the diastolic blood pressure is ≥ 90 mmHg, a specific visit should be scheduled for the assessment of hypertension . (III-A) SUMMARY STATEMENTS AND RECOMMENDATIONS
4. Women ≥ 50 years of age or postmenopausal and those with Chapter 1:
additional risk factors, such as current cigarette smoking, diabetes, and arterial hypertension, should have lipid-profile screening Assessment and Risk Management
of Menopausal Women
5 . A cardiovascular risk assessment using the Framingham Risk Score should be completed every 3 to 5 years for women aged Recommendations for Patients
50 to 75 . (II-2A) 1 . Women aged 51 to 70 should consume 7 servings of vegetables 6 . A history of past pregnancy complications (preeclampsia, and fruits, 6 of grain products, 3 of milk and alternatives, and 2 of gestational hypertension, gestational diabetes, placental abruption, meat and alterna tives daily . (III-A) idiopathic preterm delivery, and/or fetal growth restriction) should be elicited since it can often predict an increased risk for premature 2 . A diet low in sodium and simple sugars, with substitution of cardiovascular disease and cardiovascular death and may inform unsaturated fats for saturated and trans fats, as well as increased decisions about the need for screening . (II-2B) consumption of fruits, vegetables, and fibre, is recommended. (I-A) 3 . Routine vitamin D supplementation and calcium intake for all Chapter 2:
Canadian adults year round is recommended . (I-A) 4 . Achieving and maintaining a healthy weight throughout life is recommended . (I-A) 5 . Women aged 18 to 64 should accumulate at least 150 minutes of 1 . Health care providers should not initiate hormone therapy for the moderate to vigorous aerobic physical activity per week in bouts of sole purpose of preventing cardiovascular disease (coronary artery 10 minutes or more . (I-A) disease and stroke) in older postmenopausal women since there are no data to support this indication for hormone therapy . (I-A) Recommendations for Health Care Providers
2 . The risk of venous thromboembolism increases with age and 1. A waist circumference ≥ 88 cm (35 in) for women is associated obesity, in carriers of a factor V Leiden mutation, and in women with an increased risk of health problems such as diabetes, with a history of deep vein thrombosis . Transdermal therapy is heart disease, and hypertension and should be part of the initial associated with a lower risk of deep vein thrombosis than oral assessment to identify risk . (II-2A) therapy and should be considered only if the benefits outweigh 2 . Tobacco-use status should be updated for all patients on a regular the risks . (III-C) Health care providers should abstain from basis, (I-A) health care providers should clearly advise patients to prescribing oral hormone therapy for women at high risk of venous quit, (I-C) the willingness of patients to begin treatment to achieve thromboembolism . (I-A) abstinence (quitting) should be assessed, (I-C) and every tobacco 3 . Health care providers should initiate other evidence-based therapies user who expresses the willingness to begin treatment to quit and interventions to effectively reduce the risk of cardiovascular should be offered assistance . (I-A) disease events in women with or without vascular disease . (I-A) SEPTEMBER JOGC SEPTEMBRE 2014 l 831
SOGC CLINICAL PRACTICE GUIDELINE
4 . Risk factors for stroke (obesity, hypertension, elevated cholesterol 2 . Routine progestin co-therapy is not required for endometrial levels, diabetes, and cigarette smoking) should be addressed in all protection in women receiving vaginal estrogen therapy in an postmenopausal women . (I-A) appropriate dose . (III-C) 5 . If prescribing hormone therapy to older postmenopausal women, 3 . Vaginal lubricants may be recommended for subjective symptom health care providers should address cardiovascular risk factors; improvement of dyspareunia . (II-2B) low- or ultralow-dose estrogen therapy is preferred . (I-B) 4 . Because systemic absorption of vaginal estrogen is minimal, its use 6 . Health care providers may prescribe hormone therapy to diabetic is not contraindicated in women with contraindications to systemic women for the relief of menopausal symptoms . (I-A) estrogen therapy, including recent stroke and thromboembolic disease. (III-C) However, there are currently insufficient data to Chapter 3:
recommend its use in women with breast cancer who are receiving Menopausal Hormone Therapy and Breast Cancer
aromatase inhibitors (where the goal of adjuvant therapy is a complete absence of estrogen at the tissue level) . Its use in this circumstance needs to be dictated by quality-of-life concerns after discussion of possible risks . (III-C) 1 . Health care providers should periodically review the risks and 5 . Systemic estrogen therapy should not be recommended for the benefits of prescribing hormone therapy to a menopausal woman in treatment of postmenopausal urge or stress urinary incontinence light of the association between duration of use and breast cancer given the lack of evidence of therapeutic benefit. (I-A) Vaginal estrogen may, however, be recommended, particularly for the 2 . Health care providers may prescribe hormone therapy for management of urinary urge incontinence . (II-1A) menopausal symptoms in women at increased risk of breast cancer 6 . As part of the management of stress incontinence, women should with appropriate counselling and surveillance . (I-A) be encouraged to try non-surgical options, including weight loss 3 . Health care providers should clearly discuss the uncer tainty of risks (in obese women). (I-A) Pelvic floor physiotherapy, with or without associated with systemic hormone therapy after a diagnosis of biofeedback, (II-1B) weighted vaginal cones, (II-2B) functional breast cancer in women seeking treatment for distressing symptoms electrical stimulation, (I-B) and/or intravaginal pessaries (II-2B) can (vasomotor symptoms or vulvovaginal atrophy) . (I-B) also be recommended .
7. Behavioural modification, (II-2B) functional electrical stimulation Chapter 4:
(II-1B), and antimuscarinic therapy (I-A) are recommended for the treat ment of urge urinary incontinence . 8 . Vaginal estrogen therapy can be recommended for the prevention of recurrent urinary tract infections in postmenopausal 1. Lifestyle modifications, including reducing core body temperature, regular exercise, weight management, smoking cessation, and Chapter 6:
avoidance of known triggers such as hot drinks and alcohol, may be recommended to reduce mild vasomotor symptoms . (I-C) Prescription Therapeutic Agents
2 . Health care providers should offer hormone therapy, estrogen alone or combined with a progestin, as the most effective No recommendations therapy for the medical management of menopausal Chapter 7:
3 . Progestins alone or low-dose oral contraceptives can be offered Ongoing Management of the Menopausal
as alternatives for the relief of menopausal symptoms during the Woman and Those With Special Considerations
menopausal transition . (I-A) 4 . Non-hormonal prescription therapies, including certain antidepressant agents, gabapentin, and clonidine, may afford some relief from hot flashes but have their own side effects. These alternatives can be 1 . Any unexpected vaginal bleeding that occurs after 12 months of considered when hormone therapy is contraindicated or not desired . (I-B) amenorrhea is considered postmenopausal bleeding and should be 5. There is limited evidence of benefit for most complementary and investigated . (I-A) alternative approaches to the management of hot flashes. Without good 2 . Cyclic (at least 12 days per month) or continuous progestogen evidence for effectiveness, and in the face of minimal data on safety, therapy should be added to estrogen therapy if women have an intact these approaches should not be recommended . Women should be uterus; physicians should monitor adherence to the progestogen advised that, until January 2004, most natural health products were introduced into Canada as "food products" and did not fall under the regulatory requirements for pharmaceutical products . As such, most 3 . Hormone therapy should be offered to women with premature ovarian have not been rigorously tested for the treatment of moderate to severe failure or early menopause, (I-A) and its use until the natural age of hot flashes, and many lack evidence of efficacy and safety. (I-B) menopause should be recommended . (III-B) 6 . Estrogen therapy can be offered to women who have undergone 4 . Estrogen therapy can be offered to women who have undergone surgical menopause for the treatment of endometriosis . (I-A) surgical menopause for the treatment of endometriosis . (I-A) Chapter 5:
Sexuality and Menopause
1 . Conjugated estrogen cream, an intravaginal sustained-release 1 . Sexuality is multifactorial, biopsychological, and affected by estradiol ring, and low-dose estradiol vaginal tablets are psychological, relationship, physical, social, and cultural factors, as recommended as effective treatment for vaginal atrophy . (I-A) well as aging and hormonal decline . (II-2) 832 l SEPTEMBER JOGC SEPTEMBRE 2014
2 . Although desire, arousal, orgasm, and satisfaction decline with meno- Interventions should be undertaken only if the patient is distressed pause and age, the potential for sexual satisfaction still exists . (II-2) about the problem . (III-A) 3 . Decreased desire is the most common sexual problem in middle-aged 2 . The patient's problem should be categorized according to desire, women, occurring in up to 40% . However, only 12% of menopausal arousal, pain, or orgasm problems in order to facilitate treatment women are personally distressed by the problem . (II-2) and triage care . (III-A) 4 . As women age, their sexual function is affected by the presence or 3 . Vaginal estrogen therapy should be prescribed for absence of a partner and the partner's health and sexual function . (II-2) postmenopausal women with vulvovaginal atrophy and sexual 5 . Surgically menopausal women have a higher prevalence of decreased dysfunction . (I-A) libido and distress than naturally menopausal women . (II-2) 4 . For women with decreased sexual desire the current best options 6 . Satisfying sexual contact improves quality of life as women age . (II-2) include management of vaginal atrophy, addressing treatable contributing factors, and sexual counselling . (I-A) 7 . Medical and psychological illnesses and their treatment can affect sexuality . (II-2) 5 . For women with signs or symptoms of vulvovaginal atrophy who cannot use estrogens, vaginal dilators, lubricants, and 8 . Women may be reluctant to discuss their sexuality with physicians . (II-2) moisturizers should be offered . (III-B) 6. Clinicians should endorse the benefits of alternative forms of sexual contact for patients unable to have penetration . (III-A) 1 . Health care providers should acknowledge that aging women are sexual and have sexual needs but may be unwilling to initiate a SPECIAL CLINICAL SITUATIONS
discussion about problems . (III-A) Summary Statements
2 . Health care providers should be sensitive to changes in sexuality in women as they age or illnesses develop . (III-A) 1 . Sexual dysfunction is common in depressed patients and those 3 . Women and their partners should be educated about the changes taking selective serotonin reuptake inhibitors . (I) affecting sexuality that occur as women age . (III-A) 2 . Premature loss of ovarian function may be attended by sexual 4 . If women have decreased sexual desire and are not distressed, no dysfunction related to loss of both ovarian estrogen and androgen therapy is necessary . (III-B) production at a time of life when sexual activity is normally heightened . (II-1) FEMALE SEXUAL DYSFUNCTIONS
3 . Survivors of breast cancer using aromatase inhibitors have more sexual dysfunction due to vulvovaginal atrophy than do women using tamoxifen or control subjects . (II-1) 1 . Determinants of sexual function involve central and peripheral mechanisms . (II-2) 2 . Both testosterone and estrogen have effects on sexual function . (I) 1 . Patients using selective serotonin reuptake inhibitors should be 3 . The serum testosterone level is not a useful marker for the diagnosis of educated about the effects of these medications on sexuality and sexual dysfunction . (II-1) informed that these effects are reversible when the medications 4 . Estrogen's primary action is on maintenance of vaginal and vulvar are stopped . (III-B) 2 . Patients with premature ovarian failure should be asked about their sexual health . (III-B) 3 . Patients with breast cancer using aromatase inhibitors should be 1 . Vulvovaginal atrophy should be addressed in all middle-aged women advised that these medications may have sexual effects . (II-2B) who complain of sexual dysfunction . (I-A) The decision to use intravaginal estrogen therapy for severe 2 . Serum androgen measurements should not be used in the assessment vulvovaginal atrophy in such women needs to be based on quality- of female sexual dysfunction . (I-A) of-life considerations and should be made only after a discussion of the uncertain effects on breast cancer recurrence . (III-I) EVALUATION AND TREATMENT
1 . Taking a brief sexual history is part of the evaluation of the menopausal Complementary and Alternative Medicine
2 . Female dysfunction can be categorized into desire, arousal, pain, and orgasm problems . These categories often overlap . (II-2) 1 . Health Canada's Licensed Natural Health Products Database lists 3 . Low desire with distress is most common in mid-life women . (II-2) products approved for use in women with menopausal symptoms 4 . Vaginal atrophy occurs in 50% of women within 3 years of menopause that have been evaluated for safety, efficacy, and quality. (III) and is a common cause of sexual pain in menopausal women . (II-1) 5 . Sexual pain results in a cascade of detrimental sexual symptoms . (II-1) 1. Health care providers may offer identified complementary 6 . The treatment of sexual dysfunctions involves a multifaceted approach and alternative medicine with demonstrated efficacy for mild addressing medical, psychological, and relationship issues . (III) menopausal symptoms . (I-B) 7 . Transdermal testosterone therapy has been shown to increase desire, arousal, and frequency of satisfactory sexual events and to decrease personal distress for women with surgical and also natural menopause, but there are no approved products for this indication in Canada . (I) The full text of this document is available online at: 1 . Health care providers should include a short sexual screening http://www.sogc.org and http://www.jogc.com .
history as part of a medical history of menopausal women . SEPTEMBER JOGC SEPTEMBRE 2014 l 833
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