Midlife Female Health Recommendations Released

Mary Beth Nierengarten

September 24, 2014

The North American Menopause Society (NAMS) has published a compilation of key points and clinical care recommendations to address the myriad issues facing women in midlife.

Published in the October issue of Menopause, the NAMS Recommendations for Clinical Care of Midlife Women Working Group compiled the recommendations in celebration of the 25th anniversary of NAMS. They will be available free of charge on the NAMS Web site.

"We are very excited about the 25th birthday of NAMS and thought what better way to advance our mission than to summarize recommendations for women's care at midlife in a succinct, evidence-based publication that is freely available to all," Jan L. Shifren, MD, lead author of the recommendations and president of NAMS told Medscape Medical News. "We hope these recommendations will educate clinicians and result in improved care for women at this complex life stage." Dr. Shifren is also a practicing gynecologist at Massachusetts General Hospital in Boston.

A team of experts in a broad range of fields developed the recommendations, which are presented in greater detail in the NAMS premier textbook, Menopause Practice: A Clinician’s Guide. The recommendations cover all areas of women's health at midlife, including key issues specific to menopause (ie, vasomotor symptoms, osteoporosis, and vulvovaginal health), as well as more general issues related to sexual function, cognition, cardiovascular health, thyroid disease, and cancers.

The authors have graded each recommendation according to the strength of evidence to support it to provide clinicians with the best evidence to date. Level 1 recommendations are based on the best evidence (ie, good and consistent scientific evidence), level 2 recommendations are based on limited or inconsistent scientific evidence, and level 3 recommendations are based on consensus and expert opinion.

Along with providing clarity on a number of controversial issues, such as the use of hormonal replacement therapy (HRT) in peri- and postmenopausal women, the guidelines include new recommendations on a number of issues.

These include guidance on how to incorporate 3 products newly approved by the US Food and Drug Administration for use in women at midlife, Dr. Shifren explained. These products include the selective estrogen receptor modulator bazedoxifene combined with conjugated estrogen for the treatment of vasomotor symptoms and osteoporosis prevention in women with a uterus, low-dose paroxetine for vasomotor symptoms, and ospemifene for dyspareunia.

The guidelines also include updated recommendations on the use of hormone replacement therapy (HRT) in postmenopausal women based on recently published new data from the Women's Health Initiative that includes both intervention and postintervention data ( JAMA. 2013;310:1353-1368).

The guidelines provide distinct recommendations for women without a uterus considering estrogen therapy alone and for women with a uterus considering the use of estrogen plus progesterone therapy, Dr. Shifren said.

The recommendations are comprehensive, succinct, and evidence-based and will be very helpful to clinicians, Carol L. Kuhle, DO, MPH, from the Women's Health Clinic, Mayo Clinic, Rochester, Minnesota, told Medscape Medical News. Data from the newly published Kronos Early Estrogen Prevention Study (KEEPS) support the recommendation that HRT is safe during the menopausal transition, she added.

A key point in the article is that the benefits of HRT for the treatment of vasomotor symptoms outweigh the risks for select women. "Treatment of moderate to severe vasomotor symptoms is the primary indication for hormonal therapy. The benefits outweigh the risks for most healthy, symptomatic women aged younger than 60 years or within 10 years of the final menstrual period," the recommendation states.

Dr. Kuhle also said the information provided by NAMS on the use of HRT in women with primary ovarian insufficiency is important. The recommendations indicate that "Women with primary ovarian insufficiency or early menopause without contraindications to [hormone therapy] should consider the use of [hormone therapy] or combined estrogen-progestogen contraceptives until the average age of natural menopause (52 years). Longer duration may be considered for symptomatic women."

"Present trials on hormone therapy are not designed to address women with primary ovarian insufficiency. NAMS consideration for hormone therapy in this group is important," Dr. Kuhle said. "Based on epidemiologic studies, benefits far outweigh risks for hormone treatment in this population until the age of natural menopause."

Dr. Shifren emphasized that clinicians need to individualize care at midlife for women in recognition that each woman has different concerns, health problems, and risk factors. "Optimal management will vary based on her specific symptoms, personal beliefs, and medical history," she said.

The recommendation authors have disclosed a variety of financial relationships including receipt of fees from pharmaceutical companies for consulting/membership on advisory boards/honoraria, speakers’ bureaus, and grants/research support; employment at pharmaceutical companies; and ownership of pharmaceutical company stocks. Dr. Shifren and Dr. Gass have disclosed no financial relationships. A complete list of disclosures can be found at the end of the recommendations.

Menopause. 2014;21:1038-1062. Abstract

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