American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause

AACE Menopause Guidelines Revision Task Force


Endocr Pract. 2006;12(3):315-337. 

In This Article

Current Role of Hormone Replacement Therapy for Management of Menopause

As a woman ages, her ovaries progressively fail to produce estrogen. This failure often begins in the late 30s, and most women experience near-complete loss of production of estrogen by their mid-50s. Currently in the United States, approximately 35 million women are beyond 50 years of age. Each day some 2,500 to 3,500 additional women have their 50th birthday. The transition from normal ovarian function to ovarian failure is described as the menopausal transition. Although for many women menopause is asymptomatic and associated with little disruption of normal life and well-being, many women experience symptoms—sometimes severe and disabling—that considerably affect their quality of life. Although some women may be asymptomatic, estrogen deficiency is associated with hot flashes, sweating, insomnia, and vaginal dryness and discomfort in up to 85% of menopausal women. Hormone therapy (HT) is the most effective intervention for management of these quality-of-life symptoms.

The goal of menopausal HT, defined as estrogen therapy alone or a combination of estrogen and a progestational agent (E+P), is to alleviate the quality-of-life symptoms. Most women with menopausal symptoms will experience spontaneous cessation of them within 5 years after onset; however, a substantial proportion of women continue to experience symptoms beyond 5 years, and in these cases, the long-term effects of use of HT must be considered. Investigators have proposed that the hypoestrogenic state associated with menopause can adversely affect the target tissues of estrogen action, including the brain, skeleton, integument, and urogenital and cardiovascular systems; nevertheless, the effectiveness of HT in the prevention of disease remains controversial.

The initial portion of this document will provide[1] guidelines for the use of HT for the relief of menopausal symptoms,[2] evidence for consideration of short-term and long-term risks associated with use of HT, including a venous thromboembolic event (VTE), endometrial cancer, breast cancer, and stroke, and[3] a discussion of the evidence that exists for primary prevention of disease that may result from a hypoestrogenic state (osteoporosis, dementia, or cardiovascular disease).

The purpose of these guidelines is to provide a consensus opinion about the appropriate management of menopause, with an emphasis on the hormonal therapies available to clinicians. The intended target audience is endocrinologists, nonendocrinologist physicians, and interested laypersons. Evidence presented in these guide-lines was obtained through MEDLINE searches and available references developed by section heads and committee members. In addition, expert opinion was used to evaluate the available scientific literature, which was graded for treatment recommendations by evidence-based medicine guidelines and then presented in specific references in the appended reference list.

The available scientific studies cited in these guidelines have been reviewed and evaluated for strength of evidence on the basis of the definitions presented in Table 1 and Table 2 . These evidence-based guidelines are intended to identify which components of the decision-making process are objective and to facilitate the cohesive incorporation of traditional "standards" of care with scientific research paradigms. The "level of evidence" (LOE) structure, based on generally accepted evaluations of standards for evidence-based medicine, is presented in Table 1 . References involving clinical evidence will have a denotation reflecting this evaluation in the reference list.

In addition to the LOE, a recommendation grade,[1] as described in Table 2 , may be cited with the reference number in the text. This format is intended to improve the ability of the readers to apply the information presented to clinical practice.


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