The North American Menopause Society Recommendations for Clinical Care of Midlife Women

Jan L Shifren, MD, NCMP, Margery LS Gass, MD, NCMP, for the NAMS Recommendations for Clinical Care of Midlife Women Working Group


Menopause. 2014;21(10):1038-1062. 

In This Article

Chapter 2: Midlife Body Changes

Vulvovaginal Changes

Key Points

1. Postmenopausal estrogen loss and aging accompanied by physiologic, vascular, neurologic, and histologic changes may result in vulvovaginal symptoms, including irritation, burning, itching, vaginal discharge, postcoital bleeding, and dyspareunia.

2. Genitourinary syndrome of menopause (GSM), a syndrome that encompasses symptomatic vulvovaginal atrophy (VVA), may have a significant impact on the quality of life of midlife women, with effects on sexual function and interpersonal relationships.

3. Women of any age with low estrogen levels, including women with primary ovarian insufficiency, premature menopause, hypothalamic amenorrhea, or hyperprolactinemia; during lactation; or after treatment with gonadotropin-releasing hormone (GnRH) agonists/ antagonists or aromatase inhibitors, may experience symptoms of GSM/VVA.

4. The presentation, diagnosis, and treatment of vulvovaginitis caused by candida, bacterial vaginosis, or trichomoniasis in postmenopausal women are the same as in premenopausal women.

5. Vulvar dystrophies (including lichen sclerosis, lichen planus, and squamous cell hyperplasia/lichen simplex chronicus) and vulvar dysplasia or cancer may present with vulvovaginal symptoms, with pelvic examination revealing focal lesions, white plaques, denuded areas, or skin thickening.

Recommendations for Clinical Care

1. All perimenopausal and postmenopausal women should be asked about vulvovaginal and urinary symptoms at every comprehensive visit. (Level II)

2. Examination of the postmenopausal vulva and vagina should include visual inspection for plaques, skin thickening, discoloration, or lesions. White, pigmented, or thickened vulvar or vaginal lesions should be biopsied to obtain an accurate diagnosis and to rule out a premalignant or malignant condition. (Level I)

3. Any bleeding in a postmenopausal woman, including postcoital bleeding, requires a thorough evaluation. (Level I)

Body Weight

Key Points

1. The average amount of weight gained over the menopausal transition is 5 lb (2.3 kg). Weight gain is more likely to be related to aging and lifestyle changes than to menopause itself.

2. Obesity is associated with a variety of adverse health conditions and more severe vasomotor symptoms during the menopause transition.

3. A daily caloric deficit of 400 kcal to 600 kcal, regular physical activity, low fat intake, consumption of fruits and vegetables, and ongoing behavior support all have been associated with sustained weight loss.

4. The implementation of the American Heart Association's general diet and lifestyle recommendations may decrease the risk of cardiovascular and noncardiac disease.

5. Pharmacologic options for weight loss include phentermine HCl, diethylpropion, orlistat, lorcaserin, and phentermine/topiramate extended release.

6. Surgical options for weight loss include restrictive procedures, malabsorptive procedures, and mixed procedures; bariatric surgery generally effects greater weight loss in the morbidly obese and higher rates of resolution of comorbid conditions than lifestyle or pharmacologic options.

Recommendations for Clinical Care

1. All adults should be screened for obesity and offered intervention based on their body mass index (BMI) and the presence of comorbidities. (Level I)

2. Pharmacologic intervention should be considered as part of a comprehensive program including diet and physical activity in women with a BMI greater than 30 kg/m2 or BMI greater than 27 kg/m2 with comorbidities. (Level II)

3. Bariatric surgery should be considered for women with a BMI of 40 kg/m2 or higher or a BMI greater than 35 kg/m2 with comorbidities who have failed conservative measures. (Level II)


Key Points

1. Skin changes associated with menopause include decreased skin thickness and elasticity, loss of collagen, increased laxity, and wrinkling

2. More marked aging of the skin occurs with exposure to certain environmental factors, principally chronic sun exposure and smoking. Signs of skin aging include wrinkling, dyspigmentation, telangiectasias, roughness, and dryness.

Recommendations for Clinical Care

1. Healthcare providers should encourage women to reduce sun exposure and not smoke to minimize adverse skin changes caused by environmental factors and aging. (Level I)

2. To reduce photo damage to the skin, women should be advised to avoid midday sun, use sunscreen consistently, wear protective hats and clothing, and avoid tanning salons. (Level I)


Key Points

1. Hair changes, including hair loss and excessive hair growth, are common during the menopause transition and postmenopause.

2. Multiple factors, including hormonal changes at menopause, genetic predisposition, and stress, contribute to midlife hair changes.

3. Female pattern hair loss (FPHL), also known as androgenetic alopecia, and telogen effluvium are the most common patterns of hair loss.

4. The increase in the ratio of androgen to estrogen during the midlife transition may influence hair changes in women. This is evidenced by the increase in hair density that can be attained with antiandrogen treatments in some women.

Recommendations for Clinical Care

1. Before initiating treatment for hair loss or hirsutism, a thorough clinical history is required, including the onset, duration, pattern, and amount of hair loss or excess hair growth. Medical conditions and medications may contribute to hair loss or hirsutism and should be reviewed. Testing for androgen excess, chronic iron deficiency, or thyroid disorders may be indicated. (Level I)

2. Topical minoxidil 5% used once daily is an FDA-approved treatment of FPHL. Minoxidil combined with an antiandrogen such as spironolactone is commonly used in women with FPHL, although there is limited evidence to support this approach. (Level II)

3. Women with FPHL and measurable androgen excess respond differently to antiandrogen therapy compared with women with FPHL and normal androgen levels. The efficacy of antiandrogens in either group of women remains unproven because there have been no large randomized, controlled trials (RCTs) investigating antiandrogens in perimenopausal or postmenopausal women with FPHL. (Level II)

4. Hormone therapy (HT) supports hair growth as it supports other skin structures, but hair loss is not an indication for HT use. (Level II)

5. Antidandruff shampoos such as ketoconazole 2% and zinc pyrithione 1% may be used to promote scalp hair growth. Camouflaging topical sprays or keratin fibers may be used as an alternative to achieve sufficient density for the frontal hair loss in FPHL. (Level II)

6. Treatment for hirsutism focuses on a combination of hormonal therapies, peripheral androgen blockage, and mechanical depilation. Eflornithine hydrochloride is an FDA-approved topical cream that reduces the growth of unwanted facial hair in women. Waxing, bleaching, shaving, and laser treatment are other options for managing hirsutism. (Level II)


Key Points

1. One of the most common ocular complaints associated with menopause is dry eyes. Women report worse dry eye symptoms and more impact of these symptoms on daily life than do men.

2. Effective treatments for dry eyes include topical lubricants, punctal occlusion, and anti-inflammatory agents.

3. The prevalence of cataracts is higher in postmenopausal women than men of the same age.

4. The relationship between menopausal hormone therapy and glaucoma risk is complex, and further study is needed.

5. Age-related macular degeneration (AMD) is the leading cause of blindness in the United States. Although women are not at increased risk of AMD compared with men, there are more women than men with AMD due to their greater longevity.

Recommendations for Clinical Care

1. Healthcare providers should ask midlife women about eye symptoms, encourage regular eye exams, and refer for ophthalmologic consultation when indicated. (Level I)

2. As menopausal HT increases the risk of dry eye symptoms, women on HT with bothersome dry eyes should be informed of this association. (Level III)


Key Points

1. Hearing impairment increases beyond age 50 years and is associated with depression and social withdrawal.

2. Hearing loss can result from a variety of causes, including aging, head injuries, tumors, infections, ear wax, lengthy exposure to very loud noises, and possibly loss of reproductive hormones.

3. It is unclear whether the menopause transition acts as a trigger for more rapid progression of hearing loss.

4. Physiologic levels of estrogen may preserve hearing, but estrogen-progestogen hormone therapy may have a small negative effect.

Recommendations for Clinical Care

1. Women experiencing hearing loss at midlife should undergo a thorough evaluation, with treatment provided if indicated (Level I).

Teeth and Oral Cavity

Key Points

1. Tooth loss is associated with decreased skeletal bone mineral density (BMD), especially in the upper jaw.

2. Women with low BMD are more susceptible to periodontal disease.

3. Long-term oral bisphosphonate use may delay healing in alveolar bone, especially when periodontal disease also is present.

4. Estrogen deficiency is associated with gingival thinning and recession. Hormonal fluctuations also may increase periodontal inflammation and susceptibility to oral lesions.

Recommendations for Clinical Care

1. Midlife women should undergo regular dental and periodontal examinations, with cleanings and dental treatments as needed. (Level I)

2. Women should maintain good oral hygiene beyond menopause, including the regular use of fluoride-containing toothpaste and/or mouth rinses. (Level I)

3. Postmenopausal women should maintain bone health as part of supporting dental and periodontal health. They should inform their dental care providers of the results of BMD testing and the use of related medications. (Level II)