Hormone Therapy for Menopausal Women in the Primary Care Setting

Kyleen E. Swords, MS, FNP-BC


Journal for Nurse Practitioners. 2017;13(8):562-569. 

In This Article

Definition and Pathophysiology of Menopause

Menopause is defined as the natural, systemic decrease of endogenous estrogen production from the ovaries caused by the physiologic depletion of a woman's ovarian reserve.[3,4] This is a normal process in the aging female and manifests as the cessation of menses and subsequent end in fertility and, in many women, the development of VMSs.[3] The average age of menopause in the US is 51 years but can range from the mid-40s to late 50s.[1,9] Before complete cessation of menstruation, women typically experience a perimenopausal period for approximately 6 months to 2 years.[4] The perimenopausal period is characterized by VMSs and an irregular menstrual cycle that may include shorter or longer intervals between menses and heavier or lighter menstrual flow. Fluctuating hormone levels and decreasing systemic estrogen are the cause of VMSs, such as hot flashes and vaginal dryness, and an irregular menstrual pattern. When a woman has gone without menses for 12 consecutive months, she has moved from the perimenopausal period into menopause.

The decrease of endogenous estrogen that occurs in menopause is the main cause of physiologic changes that women experience during this transitional period. A woman's osteoporosis and fracture risk increases as the body's production of estrogen decreases. Bone health is dependent on estrogen's ability to stall bone resorption; therefore, as endogenous estrogen decreases with age, bone breakdown occurs more rapidly.[10] A woman's risk of cardiovascular disease (CVD) and myocardial infarction also increases with menopause and age. In the menopausal transition, the progressive loss of endogenous estrogen is associated with the loss of endothelial function of the vasculature, increasing the risk of atherosclerosis and elevated blood pressure.[11] Additionally, the reduction in estrogen affects the central nervous system by influencing temperature regulation, which is controlled by the hypothalamus.[3,6] The change in temperature regulation results in the characteristic menopausal symptoms of hot flashes, night sweats, and sleep disturbances, known as VMSs.[3] Women can also experience vaginal dryness because of the decrease in estrogen in the urogenital mucosa causing an increase in vaginal pH and a decrease in vaginal tissue secretions. This leaves menopausal women susceptible to dyspareunia and atrophic vaginal mucosa and puts them at an increased risk for urinary tract infections.[4,12]

VMSs, particularly hot flashes, are the most common reasons that women seek care during the perimenopausal and menopausal period, along with urovaginal symptoms.[3,8] The North American Menopause Society (NAMS) recommends lifestyle changes, such as regular exercise and regulation of body temperature through the layering of clothing and the use of external heating/cooling systems, as the initial step for the management of VMS, whereas suggestions for nonprescription options include the use of vitamin E, soy, and black cohosh.[3,4,7] Because the exact mechanism of estrogen depletion causing hot flashes and VMSs is unknown,[3,6,8] there are many nonhormonal prescription and nonprescription medications that can be tried before the initiation of MHT or used as an alternative if MHT is contraindicated (Table 1). These treatment methods come with their own set of contraindications and side effects, which must be considered before recommending a therapy to an individual patient.