Journal of Mid-life Health

GUIDELINES
Year
: 2022  |  Volume : 13  |  Issue : 5  |  Page : 2--51

Menopause management: A manual for primary care practitioners and nurse practitioners


Neelam Aggarwal1, Meeta Meeta2, Nirja Chawla3,  
1 Department of Obstetrics and Gynaecology, PGIMER, Chandigarh, India
2 Department of Obstetrics and Gynecology, Tanvir Hospital, Hyderabad, Telangana, India
3 Former Consultant, Department of Obst & Gynae, PGIMER, Chandigarh, India

Correspondence Address:
Meeta Meeta
Department of Obstetrics and Gynaecology, Tanvir Hospital, Plot No. 100 Phase 1, Kamalapuri Colony, Hyderabad, Telangana
India




How to cite this article:
Aggarwal N, Meeta M, Chawla N. Menopause management: A manual for primary care practitioners and nurse practitioners.J Mid-life Health 2022;13:2-51


How to cite this URL:
Aggarwal N, Meeta M, Chawla N. Menopause management: A manual for primary care practitioners and nurse practitioners. J Mid-life Health [serial online] 2022 [cited 2022 Aug 9 ];13:2-51
Available from: https://www.jmidlifehealth.org/text.asp?2022/13/5/2/351834


Full Text



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 Preface



Menopause: Setting the stage for healthy aging

With an increase in life expectancy, we expect women to live approximately one-third of their lives after menopause. In 1990, 467 million women aged 50 years, and by 2030, we expect this global figure to rise to 1200 million (World Health Organization [WHO] data). This demographic and epidemiological shift would cause noncommunicable diseases to be the primary cause of morbidity and mortality in middle-aged and older women.

We give a woman adequate care from adolescence to the reproductive-age group. Over the past decade, policymakers have become active in protecting the rights of the elderly regarding pension, health welfare, and reproductive and sexual rights. However, there is a glaring gap in managing the health issues of midlife women (45–60 years). The policymakers have overlooked midlife women as they cross the boundaries of the reproductive period and do not fall under old age.

In midlife, menopause is the most notable event. Estrogen deprivation associated with menopause causes undesirable symptoms and long-term health consequences. The health needs differ from the younger women, and health services are planned accordingly. Therefore, the International Classification of Diseases lists this natural phenomenon as a disease. A well-managed menopause transition sets the stage for active and healthy aging.

The problems of women in menopause may vary according to the geographic region. In South East Asia Region (SEAR), many countries have dedicated menopause societies working toward the cause of awareness, education, and management of these women's health needs. However, menopausal specialists are not available at all levels. Empowering and educating Primary care physician (PCPs) at the first contact level both in preventive and aspects of healthcare for menopausal women are necessary to deliver optimal care to this population segment.

The draft of the simplified manual on menopause health problems for PCPs is by extensive interactive hard work of menopausal experts across various SEAR countries, Asia Pacific Menopause Federation, Indian Medical Association, and the National Institute of Nursing in collaboration with South East Asia Regional Office (SEARO). We have taken input from the beneficiaries.

Hopefully, this document will enable the PCPs to provide optimal preventive care to the women in midlife and thus help enhance their quality of life by promoting active aging.

Chief Coordinator

Dr. Neelam Aggarwal, MBBS, MD, DGO, DHM, FICOG

Professor, Department of Obstetrics and Gynaecology, PGIMER, Chandigarh, India

President Indian Menopause Society, 2019

+91-9914209344

[email protected]

Coordinators

Dr. Meeta,

Co-Director, Consultant, Obstetrics and Gynaecology, Tanvir Hospital, Hyderabad, Telangana, India.

President, Indian Menopause Society, 2012

Editor, Journal of Mid-life Health, 2020-2022

+91-9866655597

[email protected]

Nirja Chawla,

Former Consultant, Department of Obstetrics and Gynaecology, PGIMER, Chandigarh, India

Founder Chairperson, Digital Education Committee, Indian Menopause Society

Founder President, Menopause Society Region, Chandigarh, India

[email protected]

Acknowledgment

This manual on menopausal health management for PCPs would not have been possible without support from WHO SEARO.

We greatly appreciate the technical expertise of all the experts from various menopausal societies across SEAR (Resource Faculty).

We appreciate the guidance given to us by Dr. Rama Vaidya, Founder of President, IMS, and Dr. Duru Shah, Past President, IMS.

We are thankful to Dr. Arshi Syal, Dr. Kanha Ram Patel, Dr. Rinnie Brar, Dr. Sujeet Narayan Charugulla, Dr. Tanvir, and Dr. Varun for their contribution to this manual.

We are indebted to Dr. Neena Raina, who has been the brain behind this concept and provided us with her valuable advice and arranged financial support through WHO SEARO.

From the beneficiary aspect, Mrs. Sikha Nehra, Mrs. Shashi Raju, Mrs. Anuradha, and Mrs. Rita Aggarwal gave their valuable input about problems encountered at menopause transition, which served as food for thought in addressing various issues in this manual.

Dr. Neelam Aggarwal

President, IMS, 2019

Dr. Meeta

Editor-in-Chief, IMS, 2020-2022

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 Executive Summary



Menopause basics

This manual is designed to provide basic knowledge to primary care physicians (PCPs) on different aspects of menopausal health. It provides information on the diagnosis of menopause, screening for diseases at menopause, evaluating and managing the women in midlife, and referring to a specialist as needed. The PCPs will be able to maintain the continuum of care with the knowledge gainedMenopause is a transition phase from the reproductive to the nonreproductive stage in a woman's lifeNatural age-appropriate menopause is a clinical retrospective diagnosis after 12 months of amenorrhea. Serum follicle-stimulating hormone (FSH) and other laboratory tests are usually not needed to confirm the diagnosisSerum FSH is done to diagnose early menopause (40–45 years) and premature ovarian insufficiency (POI, <40 years) in women presenting with menopausal symptoms at a young ageChanges in the duration and frequency of the menstrual cycle are considered physiological during the perimenopausal period yet need to be differentiated from pathological abnormal uterine bleeding (AUB)The menopause transition (MT) is the “window of opportunity” for PCPs to screen and treat women for noncommunicable diseases (NCDs) and malignancies to prevent long-term morbidity and mortality, promoting healthy agingThe immediate symptoms of menopause are hot flushes, night sweats, sleep and mood disturbances, joint and muscle pain, vaginal dryness, and low sexual desire, which generally resolve over a whileGenitourinary symptoms appear in the early postmenopausal period and may worsen over some time if not treatedThe long-term consequences of menopause affect bone and cardiovascular health, which worsen with agingMenopause increases the abdominal fat predisposing to metabolic syndrome. Obesity is closely related to several other chronic diseases, including heart disease, hypertension, type 2 diabetes, sleep apnea, certain cancers, and joint diseasesThe primary healthcare provider should understand the risk factors for NCDs and common cancers. The PCPs can institute timely primary intervention programs and work with specialists to treat women at risk or with the disease to prevent the life-threatening sequelaeThe approach to clinical examination should be directed to a complete health evaluation rather than addressing issues related to menopause. A thorough assessment of the health-related problems helps in formulating a treatment planIt is essential to distinguish between symptomatic and asymptomatic menopausal women and have an individualized management plan for active and healthy aging.

Screening and evaluation at menopause

The aim is to screen and diagnose specific menopause-related issues and age-related diseases and plan individualized management strategiesThe aim is to assess the general condition of a woman by clinical examination and basic laboratory tests to understand the organ functionsFor cervical cancer screening, the World Health Organization (WHO) suggests a regular screening interval of every 3 years when using Visual Inspection after Acetic acid (VIA) or cytology as a primary screening test, where HPV DNA testing is not availableThe WHO suggests a regular screening interval every 5–10 years when using HPV DNA detection as a primary screening testAfter 50 years of age, the WHO suggests stopping screening after two consecutive negative screening results consistent with the recommended regular screening intervalsThe Global Breast Cancer Initiative was introduced on March 8, 2021 (International Women's Day) by the WHO to reduce global breast cancer mortality by 2.5% per year until 2040, averting about 2.5 million deathsThe global initiative is based on interventions as three pillars: health promotion through public education, timely diagnosis by the PCPs, and comprehensive treatment and supportive care by the specialistScreening for endometrial cancer (EC) is not indicated for women with no identified risk factorsIncreased awareness of the symptoms of early ovarian cancers may help reduce the delay in diagnosis and hopefully improve outcomes.

Management of menopause

Education, counseling, and motivation have an essential role in managing menopause and related consequences.

Controlling major risk factors such as harmful use of tobacco, alcohol consumption, obesity, unhealthy diet, and physical inactivity can lower NCD risk factors and reduce premature deaths by half to two-thirds in the general population.

Promoting the concepts of lifestyle education in midlife as the first line of management will address the NCD risk and menopausal symptoms.

Prescription of a healthy diet plan is a good strategy for healthy living.

Exercise prescription will include encouraging daily activities, and a dedicated physical exercise plan helps maintain a healthy weight, improves bone density, coordination and balance, muscle strength and joint mobility, lipid profiles, and genitourinary problems, relieves depression, and induces sleep.

Social interactions, either in an exercise program or otherwise, help the postmenopausal women to improve mood, relieve depression, and relieve anxieties.

Age-appropriate adult vaccination could help reduce morbidity and mortality from vaccine-preventable diseases (VPDs).

Pharmacotherapy

The most effective treatment for vasomotor symptoms (VMSs) is systemic menopausal hormone therapy (MHT). Women needing MHT should be referred to a specialist.

Women with contraindications to MHT, or those who prefer not to use hormones, may choose to use nonhormonal medicines to relieve VMSs. These are not as effective as MHT.

Selective serotonin reuptake inhibitors (SSRIs), serotonins, and norepinephrine reuptake inhibitors (SNRIs) or clonidine are prescribed when MHT is contraindicated.

Isoflavones or black cohosh may relieve VMSs, but the evidence on the different preparations, interaction with other medicines, and safety is uncertain.

The risk of venous thromboembolism (VTE) is increased with smoking, increasing age, and obesityTransdermal appears to be safe when needed in women with the normal and at high risk for VTE.

Risks and benefits of MHT differ for women during the MT compared to those for older women. Not all MHT preparations have the same risk and side effect profile; treatment should be individualized for each patient.

 Epidemiology of Menopause and Associated Problems in the South East Asia Region



Target audience

Primary care practitioners and nurse practitioners/midwives

Learning objectives

To understand the epidemiology of menopause and associated problems in the context of South East Asia Region (SEAR) countriesTo understand the challenges of availability of menopausal healthcare in SEAR countriesTo promote skill up-gradation of primary care physicians in menopausal healthcare.

Introduction

The WHO has defined menopause as the permanent cessation of menstruation from the loss of ovarian follicular activity.[1] It is a universal and irreversible part of the aging process involving a woman's reproductive system. Menopause is diagnosed after 12 months of amenorrhea and is characterized by various symptoms. Menopause may result as a result of medical or surgical intervention. With an increased life expectancy, women now live approximately more than one-third of their life after menopause.[2]

Importance of menopausal health

The International Classification of Diseases has listed menopause, a natural phenomenon, as a disease. It supposedly alters the function of the human body resulting in menopausal symptoms termed “menopausal syndrome” that affects the quality of life (QOL). Besides, menopause may be a risk factor for various chronic diseases such as coronary artery diseases, stroke, diabetes, obesity, hypertension, osteoporosis, and urogenital problems. Commonly reported symptoms at perimenopause include changes from regular, predictable menses, hot flushes, night sweats, disturbances in sleep, frequency of urination, dryness of the vagina, poor memory, anxiety, and depression.

Studies on Asian women from different ethnic backgrounds have reported symptom prevalence rates ranging between 5% and 93%.[3] Physical and somatic symptoms predominate, followed by psychological symptoms, VMSs, and sexual symptoms.[4] Studies on menopause among African-Americans and Caucasians have reported a higher prevalence of VMSs, vaginal dryness, and psychological symptoms around menopause.[5] Therefore, in most developed countries, MHT is often recommended to prevent these distressing symptoms. Studies on issues relating to the effect of menopause on women and the feasibility and impact of MHT in the healthcare system in India and other SEAR countries are lacking. Epidemiology of Menopause in South East Asia Region is presented in [Table 1].{Table 1}

Postmenopause presents challenges to healthcare needs, for the morbidity and mortality implications after menopause are substantial; this is predominantly because of the protective effects of estrogen on the cardiovascular system and bone which disappears after menopause.[6] Epidemiology of Menopause in South East Asia Region is presented in [Table 1].[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81]

 Implementation of Menopause Care: Country-Specific Context



Target audience

Primary care practitioners.

Scope and objectives

Need

As the life expectancy nowadays is higher, there is an increase in the number of menopausal age women (global estimate of 1200 million by 2030)[1]It is estimated that by 2030, the number of postmenopausal women living in developed regions will decline to 24%, and 76% will be living in developing countries[2]The female-to-male mortality ratios from all causes except breast cancer and EC decline to low levels around menopause, rising again over the next decade to be equal in both genders. Menopause presents challenges to healthcare needs for the substantial rise in mortality after late menopause[3]Understanding the health of menopausal women and developing health promotion programs are the need of the hour. Therefore, shifting the focus of public health personnel to address middle-aged women's emerging health issues and fill the knowledge gap of service providers is essential. Strong emphasis is on improving existing medical facilities to impart better services according to the changing needs of middle-aged womenOrganized and focused training in menopausal medicine is limited even in developed countries. Recent trends in medical education have revealed the inadequacy in knowledge and skills about menopausal health and care among students and trainees, leading to frustration and potential adverse outcomes in their clinical practice in this crucial area of care for midlife womenWe have perceived menopausal medicine to differ significantly from internal medicine and other areas of medical science, as it needs to address the multifactorial nature of problems secondary to hormonal deprivation. Several vital issues need to be understood by primary care practitioners (PCP), such as need to understand the preventive aspect of diseases in postmenopausal time, lifestyle modification and involvement of the family, and other support systems that are not taught or discussed in conventional basic medical education programs.

Availability of menopausal healthcare

None of the SEAR countries has designated service delivery programs for menopausal care in either the preventive or curative arm of health services despite menopausal societies in some countries. Although Indonesia has an elderly health service post in every district, neither social insurance nor administration accepts menopausal health as a part of their services.

Level of healthcare system

Primary healthcare

Primary healthcare is central to the healthcare system. The PCP/healthcare worker is the first point of contact for the local population to provide accessible, continuous, comprehensive, and coordinated care. The need is to have a primary healthcare center with infrastructure and trained human resources to provide short-term care and simultaneously focus on the long-term health concerns of a woman. The range of services offered should be wide and appropriate to take care of the common problems in that population. Provision for coordination with specialists should be available. Therefore, primary healthcare describes the concepts and models around the single most significant player, the PCP.

A primary care physician (PCP) provided the first contact of care for an undiagnosed health problem in the short term and continued care for varied medical conditions, irrespective of course, organ system, or diagnosis.

Primary care/family medicine (FM) teams are patient-centered and can address the health needs of menopausal women both as a physician and on a social platform. Thus, ensuring a functioning primary healthcare system in society will go a long way in providing care to the ever-increasing menopausal population.

Skill up-gradation of primary care physicians in menopausal healthcare

Menopausal healthcare is not an identified subject in preservice training, in-service training, and postgraduate training, nor is the availability of postgraduate training in FM or general practice. The concept of FM or primary care teams is growing, depending on the goals and functioning of the healthcare system.

The WHO-South East Asia Regional Office (WHO-SEARO) has provided technical and financial help to the Member States in geriatric health since the late 1990s. Some such States are incorporating old-age care services into their health systems. They have attempted to address training and skill up-gradation issues by organizing short-term training programs for primary care physicians regarding service delivery but none specifically for menopausal healthcare.

India was the first country to undertake this activity. A well-designed training program, funded by the WHO-SEARO, started in 1998–1999, sensitized 180 medicine teachers in 100 medical schools for older adults, followed by short-term training to over 2000 primary care physicians over the next decade. The program created awareness among professionals, the public, and policymakers about issues related to aging and the need for dedicated services, thus providing a critical mass of health professionals trained in the care of the older population. The ultimate result of these WHO-SEARO–sponsored activities was planning and launching a National Program for Health Care of the Elderly in India.

Apart from India, The WHO-SEARO has also sponsored training programs in old-age care in Maldives, Myanmar, Sri Lanka, and Timor Leste in collaboration with WHO Country Offices and agencies of the Member States. However, these countries lack a designated national program on menopausal health management under reproductive or elderly healthcare programs.

For training PCPs in the care of menopausal women, good-quality training, uniformity of content, and involvement of the state and professional associations are essential. These programs must cover physicians in public and the private sector, as older patients seek care from any health system they can access with ease and cost-effectiveness.

The development of this manual on healthcare management of menopausal women for PCPs undertaken by the WHO-SEARO in collaboration with different menopausal societies is the first step in this direction.

Implementation of the manual

This manual is a base for sensitizing and training the PCPs at the national level. The initial step is identifying trainers from the menopausal societies, and they would conduct a trial run of the manual for training the PCPs. The training sessions would be audiovisual presentations, digital-based, physical, or hybrid with inputs from this manual.

The PCPs will receive the training material for clinical practice as soft and hard copies. We will provide the PCPs with user-friendly mobile apps (available with the Indian Menopause Society). Field testing will follow the training by PCPs in their region and changes incorporated according to local needs. After 3 months, the plan is to repeat a follow-up with an interactive training session with a pre- and post-test questionnaire. The data collected will be analyzed and used to understand the strengths and limitations of the program.

 Module 1: Basics of Menopause



Learning objective

To understand various stages of reproductive agingTo assign a diagnosis of menopauseTo understand terms and definitions related to menopauseTo counsel, treat, and refer women as needed.

Introduction

Menopause is a natural transition from the reproductive to the nonreproductive phase in a woman's life. The stages of a woman's life are depicted in [Figure 1]. Menopause is a nature's protective phenomenon against reproductive morbidity and mortality in the aging population. It sets the aging stage and speeds up the process of NCDs.{Figure 1}

Definition

The WHO defines menopause as the permanent cessation of menstruation resulting from loss of ovarian follicular activity.

According to the Stages of Reproductive Ageing Workshop, it is diagnosed after 12 months of amenorrhea following the final menstrual period with no other apparent pathological or physiological cause.

The estimated average age of menopause in the SEAR countries is 46–51 years.

Physiology

Menopause results from the loss of ovarian function and a dramatic fall in the production of the female hormone estrogen. Natural menopause occurring at an appropriate age is due to programmed cell death of the ovarian follicles and the ovaries shrink. Ovarian follicles may be destroyed due to other factors such as surgical removal of ovaries, chemotherapy, and radiation irrespective of aging, leading to premature ovarian insufficiency (POI) and early menopause.

Decreasing ovarian function causes a low estrogen level, which stimulates the pituitary gland to increase gonadotropin production to stimulate the ovary to produce estrogen. The ovary becomes less sensitive to the rising gonadotropin, and the ovary do not produce the ova (eggs).

Lack of estrogens from the ovary and increasing levels of gonadotropin, FSH and luteinizing hormone (LH), norepinephrine, dopamine, and prostaglandins at menopause affect the reproductive and the nonreproductive organs, leading to various symptoms, as depicted in [Figure 2].{Figure 2}

Diagnoses of menopause

It is a clinical diagnosis based on the history of change in menstrual patterns and menopausal symptomsIt is a retrospective diagnosis after 12 months of amenorrheaThe earliest symptom changes from predictable menses to shorter cycles <7 days in the early perimenopause or MT to >60 days of amenorrhea in the late perimenopause. Other symptoms experienced are VMSs, urogenital symptoms, and sleep and mood dysfunctionExclude pregnancy, lactation, hormonal intake, hysterectomy with intact ovaries and other causes of secondary amenorrheaLaboratory tests are not needed to diagnose menopauseSerum FSH and other tests are indicated to diagnose POI (<40 years), early menopause (40–45 years), and fertility issues and to rule out secondary causes of amenorrhoeaRefer to [Table 1] for interpreting FSH values.{Table 2}

Related definitions

Premenopause is the entire reproductive period, up to the final menstrual periodNatural or spontaneous menopause is recognized to have occurred after 12 months of amenorrhea, for which there are no obvious other pathological and physiological causesInduced menopause: Menopause may be induced through medication (temporarily to suppress ovarian function) or permanently damaged by treatments, usually for carcinogenic illnesses (pelvic radiation or chemotherapy)Surgical menopause: Menopause occurs earlier than expected when surgery involves the removal of both the ovariesPerimenopause or MT: An increased FSH, irregular menstrual cycles, and onset of menopausal symptoms characterize the onset of MT. It is immediately before and up to 1 year after the final menstrual period. The duration of MT varies from 2 to 10 years with an average of 4 years; earlier onset of symptoms relates to a more extended transition phasePOI: POI is spontaneous menopause below the age of 40 yearsEarly menopause: Spontaneous or induced menopause occurs between 40 years and the accepted typical age of menopause for a populationPostmenopausal bleeding: Postmenopausal bleeding (PMB) is vaginal bleeding following a woman's final menstrual cycle and not on cyclical hormone therapy (HT). However, vaginal bleeding that occurs 6 months after amenorrhea should be considered suspicious and warrants investigationMidlife: Typically defined as age 40–65 years, it is a challenging time for women with significant biological, psychological, behavioral, and social changes and role transition [Figure 3].{Figure 3}

During menopause, physical, biological, and emotional changes may lead to immediate and chronic problems in susceptible women. Symptoms and signs that present at menopause transition may extend beyond menopause. Symptoms associated with menopausal are irregular periods, vaginal dryness, hot flashes, chills, night sweats, sleep problems, mood changes, weight gain, urinary incontinence, sexual dysfunction, slowed metabolism, thinning hair, dry skin, and loss of fullness of the breast. In postmenopause, the risk of certain medical conditions, such as heart disease, osteoporosis, cognitive decline, and certain types of cancer, increases [Figure 3].

Advantage of managing the perimenopause or the menopause transition – “The window of opportunity”

Menopause does not need treatment. Medical treatment is required for women suffering from symptoms affecting their QOL. All women transiting through menopause need preventive care and promotion of health.

The MT is the critical “Window of Opportunity” to screen women for NCDs such as hypertension, diabetes, heart disease, and cancers to prevent long-term morbidity and mortality. It is the time to address age-related impairments of hearing, vision, and teeth.

Primary care practitioners can help optimize women's physical, mental, and psychological activities in their later years through preventive healthcare and management at the “Window of Opportunity.” Interventions such as healthy behavioral change, e.g., physical activity, healthy dietary change, smoking cessation, stress management, and healthy sleep behaviors, during the MT and midlife help prevent or delay aging chronic diseases. On indication ,women benefit from MHT when given during this window of opportunity at menopause transition.

Women may need specialist care if:

Diagnosis of menopause is uncertainHeavy menstrual bleedingSevere symptoms of menopauseMenopausal symptoms before the age of 40 years (POI)PMB.

Key points

Menopause is when a woman transits from the reproductive to the nonreproductive phase in a woman's lifeIt is a clinical, retrospective diagnosis after 12 months of amenorrhea. They usually need no tests to make the diagnosisThe MT is the window of opportunity to screen and treat women for NCDs and malignancies to prevent long-term morbidity and mortality and promote healthy agingThe changes in the duration and frequency of the menstrual cycle are considered normal at MT yet need to be differentiated from AUB.

 Module 2: Physiology and Pathology of Menopause



Learning objective

To recognize the symptoms of menopauseTo understand the short-term, intermediate, and long-term sequelae of menopause.

Menopause is a physiological transition phase in life due to declining estrogen levels and differs from illness. We may consider menopause with a multiplicity of symptoms that affect the QOL and as a biological marker for chronic diseases [Table 2]. Many women sail through menopause without problems.{Table 3}

Immediate problems

Menstrual irregularities

Changes in the duration and frequency of the menstrual cycle are considered normal at MT yet need to be differentiated from pathological AUB.

Bleeding irregularities at menopause may present as scanty and infrequent periods (70%) and heavy bleeding (18%), and there may be a sudden cessation of periods in 12% of the women.

Abnormal uterine bleeding

AUB is a frequent reason for a woman to visit her gynecologist and may present as:

Heavier than usual bleeding, over 80 ml or associated with the passage of clotsProlonged duration of bleeding of over 7 daysMenses more often than every 3 weeksBleeding or spotting between the menstrual cycle and postcoital bleeding.

Fertility issues

There is a decline in fertility by the late 30s. Oocyte donation is the only effective treatment for ovarian aging.

Preconception counseling

Women planning for pregnancy at midlife, need to be counseled about optimal general health and screening for medical conditions, such as hypertension, diabetes, and pregnancy-related risks. With age, spontaneous pregnancy loss, chromosomal abnormalities, perinatal morbidity, and mortality increase. Psychological and social problems may cause traumatic effects in the elderly couple.

Contraception

As fertility declines, women can stop using contraceptives after 1 year without periods if over 50 and after 2 years without periods in under 50.

Age is not a contraindication for any method of contraception in women aged over 40 years. An individualized assessment of the risks and benefits of each contraceptive method should be offered.

According to the WHO Medical Eligibility Criteria (MEC) for women more or equal to 40 years, combined hormonal contraceptives are a safe option. Hormone replacement therapy is not a contraceptive.

The PCP can refer MEC wheel for contraceptive.

This wheel contains the MEC to be checked before starting contraceptive methods and recommends safe and effective contraception methods for women. The wheel includes recommendations on initiating the use of nine common types of contraceptive methods.

Symptoms of menopause

Vasomotor symptoms

VMSs include hot flushes, cold sweats, and night sweats. During a menopausal flush, there is no elevation of the core body temperature. The frequency and intensity of the symptoms vary among women. With time, the incidence of hot flushes for a woman increases typically during the MT, reaches the maximum during the first 2 years postmenopause, and generally declines over the next few years. Symptoms may last longer for some women.

For reproducibility and management, hot flushes and night sweats are graded as:

Mild: Feeling of heat without sweatingModerate: Feeling of heat with sweatingSevere: Feeling of heat with sweating and palpitation that disrupts usual activity.

Duration

It lasts for a few seconds to several minutes, averaging about 3–6 min.

Associated symptoms

Sweating, flushing, palpitations, anxiety, irritability and panic may also accompany hot flushes. Some women also experience formication (the sensation of crawling on or under the skin), while others feel faint or dizzy.

There may be other causes of flushing, sweating, and palpitation during menopause.

 Systemic diseases



Anemia, thyroid diseases, migraine, Parkinson's disease, carcinoid syndrome, mastocytosis, medullary thyroid carcinoma, pancreatic carcinoma, pheochromocytoma, renal cell carcinoma, Horner's syndrome, anxiety, brain tumors, and spinal cord lesions.

 Medications



Calcium-channel blockers, nicotinic acid, anti-estrogens such as raloxifene and tamoxifen, LH-releasing hormone agonists or antagonists, aromatase inhibitors, bromocriptine, cephalosporins, cholinergic drugs, calcitonin, chlorpropamide, ketoconazole, metronidazole, opiates, and alcohol.

 Associated with eating and food additives



Hot beverages, monosodium glutamate (Chinese food), and food preservatives (sodium nitrite).

 Infections



Tuberculosis, autoimmune deficiency syndrome, and recurrent urinary tract infections.

Sexual symptoms

Among postmenopausal women, the early sexual symptoms are dryness of the vagina. They may present with sexual desire disorder, dyspareunia, and vaginismus. There may be a decrease or loss of libido.

Psychological aspects

New-onset depression, anxiety, mood changes, loss of concentration, memory problems, and sleep disturbances are common in the MT.

Intermediate

Genitourinary symptoms

Genitourinary syndrome of menopause (GSM) includes any urinary, genital, or sexual dysfunction related to the hypoestrogenic state.

GSM is usually secondary to postmenopausal estrogen loss; cancer treatments can also cause it, such as chemotherapy, radiation, and systemic endocrine therapy (e.g., tamoxifen), which cause ovarian hormonal suppression.

GSM can clinically be detected in up to 90% of postmenopausal women undergoing evaluation and affects the QOL.

Women do not complain about it; leading questions need to be asked during history taking.

Unlike VMSs, symptoms of GSM do not resolve over time, are chronic, and can become progressively worse without treatment.

Presentation

A woman may present with vulval and vaginal dryness, burning sensation, irritation, pruritus vulvae, urinary urgency, recurrent urinary tract infections, dyspareunia, and sexual dysfunction.

On examination

[Figure 4] depicts normal and atrophic vagina{Figure 4}

Physical signs of vulvovaginal atrophy (reduced vulval fat, reduced vaginal rugae, and pale appearance)Vaginal pH changes from the normal moderately acidic range (pH 3.5–5.0) to a neutral range (pH 6.0–8.0) or alkaline pH.

Risk factors for worsened genitourinary symptoms

MenopauseBilateral oophorectomyDecreased frequency and sexual abstinenceOvarian failureLack of exercise.

Physical changes

The body form changes from gynecoid to android form due to increased central abdominal fat, even without increasing total body weight.

Joint and muscle: Muscle aches, joint pains, and osteoarthritis are common in menopauseSkin: Dryness and thinning; acne may appear. Sun exposure and the use of tobacco increase the onset of wrinklesHair: Thinning of the scalp, especially frontal area and pubic hair, increases facial hair.Teeth: May have reduced salivation and gingivitis.

Long-term effects of menopause

Cardiovascular disease

Cardiovascular diseases (CVDs) include coronary heart disease (CHD, angina, and myocardial infarction), stroke, and VTE and are the leading causes of mortality in women after menopauseThe incidence of CVD increases with age in women and menIn women, decreasing estrogen levels at menopause add a risk factor for CVD. Thus, menopause may be considered a biological marker for CVD in womenWomen with POI, especially those with surgical oophorectomy, have an increased risk of CHDDuring the MT, due to estrogen deficiency, there is an increase in triglycerides and low-density lipoproteins and a decrease in high-density lipoproteinsIt is crucial that the primary healthcare provider understands the risk factors for CVD and institutes timely primary intervention programs and works with the physicians/cardiologists to prevent the life-threatening sequelae of CVDAssessment of cardiovascular risk is necessary before starting MHT. Risk factors for CVD are mentioned in the next module.

Skeletomuscular effects of menopause

These include osteoporosis, sarcopenia, and frailty.

Osteoporosis

 What is osteoporosis?



Osteoporosis is “a systemic skeletal disease characterized by low bone mass (measured as bone mineral density [BMD]) and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture.”

 Why does osteoporosis happen?



Bones constantly change through life, breaking down (resorption) and renewing (formation). Osteoporosis happens when resorption occurs more quickly than formation, leading to loss of bone strength and density. The bones become fragile and fracture more easilyIn adolescence, the formation of bone is more than resorption, and in adulthood, the formation is equal to the resorption of the bone. Here, an individual achieves the peak bone mass. Peak bone mass is influenced by several modifiable and nonmodifiable factors, including race, heredity, diet, exercise, alcohol consumption, smoking, diseases, medications, and hormones. Refer to Module 3With aging, the resorption of the bone is more than formation, and bone loss starts between 35 and 40 years of age among both sexesIn addition, in women, bone loss accelerates in the decade following menopause. Women lose 35%–50% of the trabecular bone (vertebrae, hip, and end of long bones) and 25%–30% of the cortical bone (shaft of long bones), while men lose 15%–45% of the trabecular bone and 5%–15% of the cortical bone. All this can lead to postmenopausal osteopenia and osteoporosisThroughout the lifespan, secondary factors may deplete bone mass and precipitate osteoporosis.

 What is the presentation of osteoporosis?



Osteoporosis is an asymptomatic silent disease until the occurrence of a complication, which is an osteoporotic or fragility fracture. It usually involves the wrist, spine, hip, pelvis, ribs, or humerus (WHO).

 What is a fragility fracture?



As defined by the WHO, fragility fracture is a fracture by an injury that would not fracture a normal bone. Clinically, fragility fracture occurs because minimal or no trauma even falls from a standing height or torsional movement of the spine. Common sites of fragility fractures are the hip, spine, and forearm.

 What are the consequences of osteoporosis?



Osteoporotic fractures have led to a significant increase in morbidity and mortality and an enormous financial burden. All these factors make osteoporosis a significant public health problemThere is a loss of height, spinal curvature, significant morbidity and mortality due to hip fracture, and social and economic burden on the familyGenerally, the risks in men are about half those of womenOsteoporotic fractures are expected to increase in both men and women (by over 3-fold over the next 50 years) because of the aging populationHip fractures are the most severe of these fractures and are associated with significant morbidity and mortalityA significant collapse of one vertebral body usually leads to severe pain. In addition to repeated pain, numerous crush fractures result in loss of height and, often, in a marked kyphosis. The kyphosis, in turn, may lead to cardiopulmonary embarrassment and severely reduced exercise tolerance and functional impairment.

 How to diagnose osteoporosis?



The presence of a fragility fracture (clinical or radiological) and measurement of BMD testing by dual X-ray absorptiometry (DXA)According to WHO criteria, osteoporosis is a BMD that lies 2.5 standard deviations (SDs) or below the average value for young, healthy women (a T-score of <−2.5 SD)The WHO definition of osteoporosis applies to postmenopausal women and men aged 50 years or older [Table 3]The reference standard for diagnosing osteoporosis is the femoral neck BMD, total hip, and lumbar spine, which can be used for diagnosisEach SD reduction in BMD increased the relative fracture risk 1.5–3 times.{Table 4}

Sarcopenia

The primary parameter of sarcopenia is low muscle strengthDiagnosis is confirmed clinically by low muscle quantity or quality and low physical performance. DXA measures the quantity of appendicular muscle mass, and magnetic resonance imaging measures the whole-body skeletal muscle massSarcopenia predisposes to frailty, physical impairment, poor QOL, and death.

Frailty

Frailty is “a physiologic syndrome characterized by decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems, and causing vulnerability to adverse outcomes” (Linda Fried et al., 2003)It is diagnosed as three or more of the following criteria: unintentional weight loss, self-reported exhaustion, weakness (grip strength), slow motor performance (walking speed), and low physical activityIt leads to disability, dependency, and increased risk of falls and mortality. Increased risk of falls leads to fear and loss of confidence and decreases the QOL.

Refer to specialist

When symptoms do not respond to lifestyle managementSevere VMSs, neuropsychiatric symptomsAUB, PMBHigh risk for CVD, osteoporosis, sarcopenia, and frailty.

Key points

The immediate symptoms of menopause are hot flushes, night sweats, sleep and mood disturbances, and dyspareunia which generally resolve with timeThe intermediate presentation of the genitourinary syndrome may worsen over time without timely treatmentThe long-term effects of menopause and aging are on CVD and skeletomuscular healthWomen may present to primary care physicians with menstrual problems or menopausal symptoms or request a general health checkup.

 Module 3: Evaluation at Menopause



Learning objectives

To assess the general health statusTo elicit the relevant clinical information from the patient's medical history, physical examination, and diagnostic investigationsTo assess various risk factors for chronic disease and cancers.

General history, clinical examination, and investigations

The aim is [Flowchart 1]:[INLINE:4]

To identify individual woman's risk factors for various age-related diseasesTo identify individual woman's risk factors for specific menopause-related issuesTo evaluate the need for treatmentTo check the general condition of the woman and plan management strategies.

History

The information gathered should include the following areas.

Complaints

A detailed history of symptoms [Flowchart 2] related to menopause is documented in a score sheet called the menopause rating scale. The scoring system helps understand the severity of symptoms and guides evidence-based management and follow-up accordingly [Refer to Clinical Aids for Menopause Rating Scale].[INLINE:5]

Gynecological history: Current menstrual status, age at menarche/menopause, last menstrual period, flow pattern before menopause, and contraceptionObstetric history: Number of pregnancies, abortions, living children, lactation, postpartum depression, history of gestational diabetes, gestational hypertensionSurgical history: Any surgery in the past gynecological or nongynecologicalFamily history: Chronic disorders such as diabetes mellitus, hypertension, CVD, stroke, cancers, early menopause, osteoporosis, Alzheimer's disease, and rheumatoid arthritisMedical history: Same as abovePersonal history: About diet, physical activity, mental attitude, social relationship, habits, stress, mood changes, memory and concentration, caffeine use, and tobacco and alcohol consumption. Details of bowel and urinary dysfunctionSkeletomuscular: Body and joint pains, unintentional weight loss, loss of height, low physical activity, weakness, and exhaustionMedication history: Current medication, use of prescription and nonprescription drugs, complementary and alternative therapies, allergies to any medication, and use of therapy to treat menopause symptoms and contraceptive methodsSexual history: Ask about the history of difficulty in having sexual relations and lack of sexual desireWeight history: Any changes in total body weight and the waistImmunization history: History of immunization against common infections such as hepatitis B (HEPB), Haemophilus influenzae, DT booster, and COVID-19.

Clinical examination

Women may present with menstrual problems, or menopausal symptoms or request a general health checkupIt is essential to distinguish between symptomatic and asymptomatic menopausal womenThe approach to clinical examination is directed to complete health evaluation rather than addressing issues related only to menopause. A thorough assessment of the health-related problems helps in formulating a treatment plan.

An examination can be broadly divided into the following categories:

General physical examination

Height (cm)Weight (kg)Body mass index (BMI) (kg/m2) (normal range - 18.5–25)Waist circumference (WC, cm) is used to define central obesity. Up to 80 cm is normalPulse (beats/ min)Blood pressure (BP)

Optimal BP (<130/85 mmHg) to be rechecked every yearNormal level BP (<140/90 mmHg) to be checked more frequentlyBP above 140/90 mmHg needs a second measurement to confirm the diagnosis of hypertension

Conjunctiva, tongue, neck, nails, pedal edema, and varicose veinsAuscultation of the heart and lungs.

Skeletomuscular health

Check spine curvature, gait, knee flexion, and extension. A case-finding strategy starts when a patient reports symptoms or signs of sarcopenia such as a history of falls, feeling weak, slow walking speed, difficulty rising from a chair, or unintentional weight loss. In such cases, testing for sarcopenia is recommended using SARC-F Questionnaire and assessing strength by grip strength and chair stand test. Refer to Clinical Aids.

Breast examination

This needs to be carried out regularly because of an increased risk of breast cancer as women get older. Advise self-breast examination on the same day of every month.

Abdominal examination

Any organomegaly, free fluid, hernial sites, and abnormal veins.

Pelvic examination

This is done to assess for complications of menopause, such as urogenital atrophy, a Litmus test for vaginal pH and must include a Papanicolaou (Pap) smear/liquid-based cytology (LBC)/VIA as per the availability.

Eye checkup

Intraocular pressures, refractive index, and retinal examination

Dental checkup

A dental check and hygiene neds to be reinforced.

Investigations

These are necessary to determine etiology, screen for complications, and establish a diagnosis. Some investigations may be necessary to help formulate a treatment plan [Table 4].{Table 5}

Laboratory tests (ideal)

Blood

Complete blood countFasting blood sugar or Hb1Ac, or 75 g oral glucose tolerance test. Refer to Clinical AidsLipid profile – Refer to Clinical AidsSerum thyroid-stimulating hormone (TSH).

Urine

Urine routine examination.

Stool

Stool for occult blood.

Investigations to rule secondary cause of osteoporosis

Complete blood picture, erythrocyte sedimentation rate (ESR)Random blood sugarSerum calciumPreferably fasting serum phosphorusSerum creatinineSerum albuminAlkaline phosphataseSerum TSH25-hydroxy-vitamin DX-ray of thoracolumbar spine (lateral view)Parathyroid hormone (PTH) (based on clinical judgment).

Risk assessment for chronic diseases [Table 5]{Table 6}

When to refer

Severe symptoms of menopauseDiagnosis of medical disorders on routine evaluationEye, ear, and dental checkup as per need

Key messages

Women may present with menstrual problems, menopausal symptoms, or request for a general health checkupThe approach to clinical examination should be directed to complete health evaluation rather than addressing issues related only to menopauseA thorough assessment of the health-related problems helps in formulating treatment planIt is most important to distinguish between symptomatic and asymptomatic menopausal women.

Module screening for cancers

Learning objective

To understand the importance of opportunistic screening.

Cancer breast

Types of breast cancer

Ductal carcinoma (arising from the epithelium of the ducts) constitutes 85% and glandular (arising from the glandular lobules) about 15% of the breast cancer cases.

Family history of breast cancer

The personal risk of breast cancer is marginally increased if a single relative develops breast cancer after menopause. The risk doubles if two first-degree relatives develop breast cancer after 50 years or a single relative develops breast cancer before age 50. The risk quadruples in women with two first-degree relatives are affected before age 50; they should be offered genetic testing.

Screening for breast cancer

A primary strategy for reducing breast cancer mortality is to detect it at an early stage or preclinical stage. Practical and simple treatment is available for the early stages of breast cancerIn advanced cases, survival rates fall dramatically regardless of the setting. In poor-resource countries, women present at a late stage due to the absence of screening strategiesThe debate about the importance of screening continues. There are no universal evidence-based guidelines for breast cancer screening at presentIn developing countries, screening is an “opportunistic screening”According to the WHO, low-cost screening approaches, such as clinical breast examination (understanding the feel of the normal breast, reporting at the earliest in case of nipple discharge, lump, changes in the skin of the breast) could be implemented in limited-resource settingsBreast cancer control as a part of the national cancer control programs and integrated into NCD prevention and control is the agenda of the WHO.

The screening methods are:

Breast cancer screening includes three methods of early detection. Refer to Clinical Aids.

Breast self-examination (BSE) monthly starting in the 20sClinical breast examinations (CBE) every 1–3 years starting in the 20s till 39 and annually after thatScreening by mammography should start at 40 years (annually)

Breast cancer prevention

The Global Breast Cancer Initiative was introduced on March 8, 2021 (International Women's Day) by the WHO to reduce global breast cancer mortality by 2.5% per year until 2040, averting about 2.5 million deathsThe global initiative is based on interventions as three pillars: health promotion, timely diagnosis, and comprehensive treatment and supportive careThe first pillar, health promotion, includes public education on the signs and symptoms of breast cancer and advice on reducing the risk by tackling obesity, encouraging breastfeeding, and limiting alcohol intakePrimary care physicians and health workers are trained in the early detection of breast cancer. An early breast cancer diagnosis reduces delays between the time a patient first visits the health personnel and the initiation of breast cancer treatment. Essential diagnostic services are workable in all settings, so long as they are well organized and lead to a timely referral for specialist careComprehensive breast cancer treatment should include access to surgery, chemotherapy and radiotherapy, and rehabilitation support for women following treatment and palliative services to reduce pain and discomfort.

Cancer cervix

Screening women in the target age group can prevent most cervical cancers, followed by treatment of detected precancerous lesionsAfter menopause, the vagina and cervix undergo atrophic change and affect the quality and adequacy of smears takenThe basal and parabasal cells being present at the surface may lead to misleading results of dysplasiaIt is advisable to take a smear in cases of vulvovaginal atrophy after a short course of local estrogen therapy. This has a beneficial effect on the vaginal and cervical epithelium and enables a more adequate and accurate interpretation of the sampleWHO recommends starting cervical cancer screening at the age of 30 yearsAfter age 50, the WHO suggests stopping screening after two consecutive negative screening results consistent with the recommended regular screening intervalsWhen tools are available to manage postmenopausal women, women aged 50–65 years who have never been screened should be prioritizedWhere HPV DNA testing is not yet operational, the WHO suggests a regular screening interval of every 3 years when using VIA or cytology as a primary screening testThe WHO suggests a regular screening interval every 5 or 10 years when using HPV DNA detection as a primary screening testWhile transitioning to a program with a recommended regular screening interval, screening even twice in a lifetime is beneficialVIA and ablation treatments are not suitable for screening women in whom the transformation zone is not visible. Inadequate visualization is typical after menopause.

Cancer endometrium

Screening for EC is not indicated for women with no identified risk factorsWomen at average risk of EC should be informed about the symptoms and signs and report any unexpected bleeding or spottingWomen with increased risk and special situations such as MHT, genetic risk, and tamoxifen therapy are recommended for a complete diagnostic evaluation for abnormal bleeding.

Cancer ovary

A heightened awareness of the symptoms of early ovarian cancers on the parts of the patients and practitioners may help reduce the delay in diagnosis and hopefully improve the outcome of some progress. There are no screening protocols.

If any of the unusual symptoms listed below lasting for more than 2 weeks, advise an ultrasound of the abdomen and pelvis.

Abdominal bloating, indigestion, or nauseaChanges in appetite, pressure in the pelvis or lower backFrequency and/or urgency to urinate and constipationChanges in bowel movementsIncreased abdominal girthTiredness or low energy.

When to refer

Breast lump or discharge from nipple/abnormal sonomamogram and mammogramAbnormal cervical cancer screening test reportPMBAbdominal bloating, indigestion or nausea, changes in appetite, and pressure in the pelvis or lower back lasting for more than 2 weeks.

Key messages

Promote SBE and CBEAfter age 50, the WHO suggests stopping cervical screening after two consecutive negative screening results consistent with the recommended regular screening intervalsWhile transitioning to a program with a recommended regular screening interval, screening even twice in a lifetime is beneficial for cervical cancerScreening for EC is not indicated for women with no identifiable risk factorsIncreased awareness of the symptoms of early ovarian cancers may help reduce the delay in diagnosis and hopefully improve survival ratesFor the general population, annual pelvic examination and screening tests as guidelines are recommended as a part of postmenopausal surveillance.

Premature ovarian insufficiency

Learning objectives

To identify, define, and understand the risks of POITo manage and monitor POI.

Definition

Loss of ovarian hormonal function leading to menopause in women before the age of 40 years is called POI.

Premature ovarian failure or POI – If it happens spontaneously.Induced or iatrogenic menopause followingChemotherapy and radiotherapyBilateral oophorectomy or surgical menopauseFollowing hysterectomy, women have cessation of ovarian function 4 years earlier than natural expected course.

Diagnosis

Clinical syndrome is characterized by

Age <40 yearsChanges in menstrual pattern: irregularity ≥4 months of scanty periods or no periodsThere is no withdrawal with hormones, and the other signals are inability to get pregnant and symptoms of menopauseIn any woman under 45 years of age, menstrual irregularity lasting longer than 3 months should be investigated for early menopause.FSH in the menopausal range >25 IU/L on two occasions ≥1 month apart

Natural pregnancy with premature ovarian insufficiency

50% of these women experience infrequent ovulation after diagnosis, and 5%–10% may achieve spontaneous pregnancies.

Effects of premature ovarian insufficiency

Immediate

VMSs, infertility, impaired cognitive function, genitourinary syndrome, and decrease in QOL.

Long-term effects

 Osteoporosis



Women with untreated POI are at increased risk of developing osteoporosis, and fracture risks are 1.5–3-fold more than the risk of fracture in women attaining menopause at the average age.

Measurement of BMD at initial diagnosis of POI should be considered for all women.

There is an increased risk of other conditions, including CVD and mortality, type 2 diabetes mellitus, genitourinary syndrome, dementia, cognitive decline, and overall mortality.

 Management



Healthy lifestyle helps in managing menopausal symptoms, prevents CVD, and protects bone and muscle [Table 6].{Table 7}

 Vasomotor symptoms



The mainstay of treatment is complete replacement hormone therapy (HRT). It should be started as early as possible after the diagnosis is confirmed and continued until the age of natural menopauseHT is not a contraceptive method [Table 6]No evidence shows that estrogen replacement increases the risk of breast cancer to a level more significant than that found in normally menstruating women, and women with POI do not need to start mammographic screening earlyHT in POI is a long-term therapy, and hence, it is recommended that the dose of HT is kept as physiological as possible.Progestogen must be added to avoid the unopposed effects of estrogen on the endometrium in a woman with a uterus. Levonorgestrel intrauterine system has the advantage of avoiding the adverse systemic effects of oral progestinsThe flowchart of management is given in Chapter “Hormonal Therapy”Using combined hormonal contraceptives is acceptable. There are no head-to-head trials comparing the use of HRT versus combined hormonal contraceptives in POIGuidelines and data show the preferential use of MHT if contraception is not needed based on the theory of minimum effective dose for any ailmentIf HT is contraindicated, options for management are gabapentin, SSRI and serotonins and SNRIs.

Genitourinary syndrome

Regular sexual activity helps maintain vaginal health, vaginal moisturizers and lubricants, and topical low-dose estrogens.

Monitoring

Women with POI using HRT should have a clinical review annually, paying particular attention to compliance. No routine monitoring tests are required but may be prompted by specific symptoms or concerns.

Measures to prevent premature ovarian insufficiency

Given the long-term health consequences of POI, efforts should be made to reduce the incidence.

Modifiable factors may include:

Gynecological surgical practice - There is a great need for an awareness program about the consequence of surgical menopause risk/benefits and the prevention of problems due to surgical menopauseLifestyle - Prevention of smoking, use of tobacco, optimal weightModified treatment regimens for malignant and chronic diseases.

When to refer

For treatment of POI.

Key messages

Loss of ovarian hormonal function leading to menopause in women before 40 years of age is called POI.They may present with the VMSs, genitourinary syndrome, infertility, and decreased QOLWomen with untreated POI are at increased risk of developing osteoporosis, cardiovascular mortality, and overall mortalityEarly menopause is associated with an increased risk of developing type 2 diabetesManagement includes hormone replacement therapy unless contraindicated.

Obesity at menopause

Learning objective

To understand the definition and sequelae of obesity at menopauseTo understand the management of obesity.

The WHO considers obesity the most significant global chronic health problem in adults, increasingly becoming a more severe problem than malnutrition.

Definition

Obesity is an abnormal or excessive fat accumulation that may impair health.

Menopause and obesity

Women around menopause gain on an average of 0.55 kg (>1 lb) per yearAssociation of weight gain around menopause is linked more with lifestyle and agingThe menopausal transitionEstrogen promotes the accumulation of gluteofemoral fat (gynecoid or pear shape). Estrogen decline with menopause is associated with an increase in fat centrally, as intra-abdominal fat (android or apple shape) is independent of the effect of age and total body fatAndroid obesity has emerged as a cardiovascular risk factor independent of overall obesityA healthy lifestyle helps at any age but is even more critical around menopause.

Benefits of maintaining a healthy weight and waist circumference at menopause

The risk for following NCDs increases with a rise in BMI and visceral obesityObesity may precipitate more severe menopausal symptoms. Losing weight helps improve symptomsCVDs (heart disease, stroke, VTE), type 2 diabetes, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, sleep apnea, osteoarthritis, gastroesophageal reflux, incontinence, intertrigo, thrombosisCancers such as endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colonDepression, low self-esteem, cognitive impairmentWeight loss of 5%–10% and reducing abdominal fat by maintaining a healthy weight can decrease the risk of these diseases.

Diagnosis of obesity

Obesity is measured by a scale, BMI, abdominal obesity by WC and waist-hip ratio.

Measuring body mass index

BMI is derived by dividing a person's weight in kilograms by their height in meters squared and expressed as kg/m2.

Measuring waist circumference and waist-hip ratio

The WHO STEP-wise approach to surveillance (STEPS) protocol for measuring WCThe WC is measured at the end of several consecutive natural breaths parallel to the floor. The level is at the midpoint between the top of the iliac crest and the lower margin of the last palpable rib in the midaxillary lineMeasure the hip circumference at a level parallel to the floor, at the largest circumference of the buttocksMake both measurements with stretch-resistant tape wrapped snugly around the subject but not to the point that the tape is constricting. At the point of measurement, keep the tape level and parallel to the floor atEnsure that the subject is standing upright during the measurement, with arms relaxed at the side, feet evenly spread apart, and body weight evenly distributedThe WC and BMI are used as more sensitive indicators of disease risksBased on BMI and WC, a staging system is used to assess risk and plan management [Table 7], [Table 8], [Table 9]{Table 8}{Table 9}{Table 10}

Key messages

Obesity is closely related to several other chronic diseases, including heart disease, hypertension, type 2 diabetes, sleep apnea, certain cancers, and joint diseasesMenopause does not cause obesity; it increases the abdominal fat predisposing to metabolic syndromeA healthy diet and physical activity are essential to prevent obesity.

 Module 4: Management of Menopause



Learning objective

To understand the management optionsLifestyle modification for health promotion, disease prevention, and disability postponement.MHTNonhormonal options in women not willing or suitable for MHT

Management of menopause

The management depends upon the symptoms, comorbidities, lifestyle, socioeconomic status, and acceptance.

In symptomatic and asymptomatic women, prevention of disease should be emphasized [Flowchart 3].[INLINE:6]

Classifying the woman into two groups based on symptoms helps in planning an individualized management:

Group 1: Women without menopausal symptoms [Table 10]Group 2: Women with menopausal symptoms [Table 11].{Table 11}{Table 12}

Management options

Therapeutic lifestyle management is universal for preventive healthcare and never too early nor too late to enforce for an asymptomatic or symptomatic womanFor women with symptoms, treatment options fall into three categories:

MHTNonhormonal prescription treatmentsComplementary therapies.

Therapeutic lifestyle management

Learning objectives

To understand the importance of maintaining an ideal weightTo understand nutrition, physical activity, exercise, and sleepTo understand the use of calcium and Vitamin DAdult vaccination.

Menopause transition - “Window of opportunity”

A healthy lifestyle during the MT is associated with decreased NCDs, thus promoting healthy aging and preventing disabilityCounselling on controlling modifiable major risk factors such as the harmful use of tobacco, alcohol consumption, obesity, unhealthy diet and physical inactivity is needed.The interventions that lower NCD risk factors can reduce premature deaths by half to two-thirdsSecondary prevention through healthy living retards the progression of existing chronic diseases and decreases mortality.

Therapeutic lifestyle management includes counseling regarding:

Dietary patternPhysical activity and exerciseAvoid the use of tobacco, gutka, paan, alcohol, and recreational drugsPositive thinking, stress management, relaxation techniqueSleep hygiene.

General tips on nutrition

Diet should be balanced and nutritious and follow the food-based dietary guidance of their countries [Figure 5]There should be a balance between energy intake (calories) with energy expenditureFat content should not be over 30% of total energy intake; saturated fats should be less than 10%, and transfats should not be less than 1% of total energy intakeIntake of free sugars is limited to less than 10% or preferably 5% of total energy intake for additional health benefits. Limit consumption of free sugars, which only have empty caloriesHave about 100 g of fruits and 300 g of vegetables. Prefer whole fruits rather than juicesInclude whole grains, beans, and lentils dailyCertain foods with antioxidants (green, yellow, and orange vegetables and fruits, such as carrots, sweet potatoes, spinach, tomato, and orange) are recommendedEat 1–3 servings per week of oily fish like salmon and mackerel.Foods rich in phytoestrogen include lentils, kidney beans, bengal gram and soybean.Snack on four nuts like almonds, walnuts or and seeds like pumpkin, sunflower, sesameUse mixed protein; adequate intake would be about 1 g/kg/day.Consume 500–600 ml of milk or curds (low fat) for bone health, and support it with lots of vitamin C-rich fruits/vegetables to favour calcium absorption.Use iodised salt, and overall intake should be less than 1 tsp per day, i.e. 3–5 g (2 g of sodium)Drink eight glasses of water every day.{Figure 5}

To avoid

Excess caffeine (coffee, tea, and soft drinks)Processed, canned, frozen, and packed foods, soups, and salted nuts

Each component represents proportion: about half for vegetables, about one quarter for protein-rich food (meat, fish, cheese, and legumes), and the last quarter for starchy food, including cereals and grains. Fruits are shown on the periphery of the plate because they can be eaten between meals (apples, berries). (From diet: http://nutrition-sante.ch/l-assiette-equilibree).

Calcium

Calcium is an essential component of bone mass. It affects the cardiovascular system, nervous system, and muscles as wellCalcium supplementation up to 1000 mg/day reduces bone loss and decreases fractures in individuals with low calcium intakePremenopausal women need 1000 mg of calcium, while postmenopausal women should consume 1200 mgLimit calcium intake to 500 mg at one time from food and/or supplementCalcium absorption is decreased with smoking, caffeine, stress, and when taken with foods rich in fibers and fat, iron, zinc, spinach, coffee, alcohol, and antacidsHigh salt intake is linked with an increase in urinary calcium lossLack of dietary nutrients also reduces calcium absorption, especially Vitamins C, D, and K, and minerals such as magnesium and phosphorusDrugs such as thyroid medications, corticosteroids, tetracycline, and anticonvulsants should be taken separately from calciumEncourage calcium intake from dietary sources. Dietary Sources of Calcium - Refer to Clinical Aids.

Vitamin D

Along with calcium, Vitamin D decreases bone loss, prevents falls, and lowers fracture riskFor effective calcium absorption, an adequate amount of Vitamin D must be presentAbove 50 years and older, women need 800–1000 IU dailyVitamin D is typically synthesized in the skin by exposure to UV rays of sunlightAt least 15%–30% of body surface area needs to be exposed (face, neck, arms, and forearms) without sunscreen for at least 15–30 min, depending on the season, latitude, altitude, pollution, and skin pigmentationDietary sources are limited to fatty fishes such as wild-caught mackerel, salmon, and tunaWhen it is not possible to get Vitamin D from the sun or diet, it is recommended to use Vitamin D as a supplement.

Management of deficiency

Cholecalciferol (Vitamin D3), 60,000 IU/orally once a week for 8 weeks, preferably with milk.

This is followed by maintenance therapy.

 Maintenance therapy



Vitamin D supplements of 1000–2000 IU/day.

 Upper acceptable limit



The dose for treatment should not exceed 4000 IU/day, and hypercalcemia has been reported when the dose exceeds 10,000 IU/day.

Vitamin D derivatives

Calcitriol, the active form of Vitamin D, is reserved only for chronic renal and hepatic disease patients.

Addictions

Tobacco is linked with early menopause up to 2 years earlier, more likely to develop VMSs, osteoporosis, and increased atherosclerosis in the coronary arteriesAlcohol: Pure alcohol of more than three units (30 ml) precipitates VMSs at menopause and can increase the risk of breast cancer.

It raises BP and increases the risk of heart disease and stroke, osteoporosis, depression, stress, dementia—difficulty sleeping and relationship problems.

Stress management, relaxation technique

Mental and emotional well-being may be maintained by being a learner, pursuing a hobby, continuing work, reading, conversing, meditating, spirituality, bonding with family and friends, and participating in social activity.

Sleep hygiene

Getting to bed and getting up at the same time each daySleep in the dark, quiet room at a comfortable temperatureAvoid large meals, exercise, caffeine, nicotine, gadgets, television, and liquid 2 h before sleepMaintain a dim light bedroom environment with no gadgets aroundAvoid disturbing thoughts or problems, meditate, and keep the mind peacefulMind–body therapies such as yoga and tai chi may be triedIn resistant cases, short-term melatonin agonists and benzodiazepines may be given before referring to a psychiatrist.

Physical activity and exercise

Physical activity is any bodily movement produced by the muscles [Figure 6].{Figure 6}

Exercise is a type of physical activity planned, structured, repetitive, and purposeful to improve or maintain some component of fitness or health.

Both are important for health.

Exercise should include aerobic, strength/weight-bearing, flexibility, breathing, and balance.

30 min or bouts of at least 10 min duration of moderate-intensity physical activity should be included mostly 5 days a week.

Muscle-strengthening activities should be included at least 2 days/per week.

Duration of exercise depends on the aim of fitness to be achieved:

30 minutes/day – For fitness and reduced risk of chronic disease60 minutes/day – For prevention of weight gain

60–90 minutes/day – To avoid the gain of weight

Types of exercises

It is recommended to be on an empty stomach at least 2 h before exercise.

Warm-up and cool-down include gentle stretching and flexibility exercises performed for 5 10 min before and after aerobics and strength training exercisesAerobics improves cardiovascular fitness by increasing the capacity to use oxygen by walking, running, and cyclingStrength training/resistance training /weight-bearing – to build strength and size of the muscle and bone. Strength training utilizes machines, dumbbells, and ankle or wrist weights. Weight-bearing exercises include tai chi and dancingStretching – a specific muscle group is stretched out to improve muscle and joint elasticity and flexibilityBreathing exercises – to increase the oxygen-carrying capacity and recharge the mind, body, and distressBalance exercise – to maintain correct posture and balanceKegel exercise – to maintain pelvic floor strength.

Healthy women can probably undertake such a program without medical screening. Those who have any medical problems or symptoms (e.g., chest pain, dyspnea, syncope) should be evaluated thoroughly for fitness before beginning the exercises.

Avoid high-impact activities or those that require sudden, forceful movements, and forward bending in case of osteoporosis.

Immunization in adults

Learning objectives

To know the adult vaccination schedule.

Vaccination in an adult could pave the way to preventing many infective pathologies. There are no national guidelines for adult vaccination in IndiaAdult vaccination could help reduce morbidity and mortality from VPDsNatural immunity reduces over time in older adults, and comorbidities such as chronic cardiac, pulmonary, or metabolic diseases make them more susceptible to VPDs.

Some VPDs in older adults can be severe, resulting in high morbidity and mortality rates.

Hepatitis B

Indications/comments: Vaccination is indicated for all unvaccinated adults at risk for HEPB virus (HBV) infection and all adults seeking protection from HBV infection, including postexposure prophylaxisDosage/administration: Three doses (1 ml each) intramuscularly on a 0, 1, and 6 months schedule.

Influenza

It is indicated for every patient over age 65 years, 1 pregnant women, and women with immunocompromised sickle cell disease, chronic renal disease, CSF leak syndrome, cochlear implants, chronic lung or cardiac illness, asthma, a history of smoking, or chronic metabolic

Herpes zoster vaccine

Indications/comments: A single dose of the zoster vaccine is recommended for adults aged 50 years and older regardless of whether they report a prior episode of herpes zosterDose: 0.65-ml dose subcutaneously in the deltoid region of the upper arm.

Diphtheria, tetanus, and acellular pertussis 31 vaccine

Indications/comments: Adults who have completed their primary vaccination series should receive tetanus (TD) vaccine every ten years till the age of 65 years; In unvaccinated individuals, one dose of diphtheria, TD, and acellular pertussis 31 vaccine may be administeredDose: 0.5 ml intramuscularly once.

Polysaccharide pneumococcal vaccine

Indications/comments: Polysaccharide pneumococcal vaccine 23 is indicated for adults over age 65 years and adults under age 65 years who are at riskDosage/administration: 0.5 ml given intramuscularly as 2 doses 5 years apart.

COVID

Indications/comments: Indicated for all adults as per the current schedule. The time interval between two doses of the Covishield vaccine has been extended from 4–8 weeks to 12–16 weeks. The second dose of Covaxin can be taken 4–6 weeks after the first.

Vaccines recommended for all healthy adults

Diphtheria, pertussis, and tetanusMeasles, Mumps, and RubellaInfluenza (>50 years)Pneumococcal (>65 years)Zoster (>60 years).

Vaccines recommended in At -Risk individuals

Hepatitis BHepatitis AMeningococcalVaricellaHiBTyphoidRabies.

Cholera and Japanese encephalitis vaccines are routinely not indicated due to a lack of adequate evidence.

At-risk individuals immunocompromised sickle cell disease, chronic renal disease, CSF leak syndrome, cochlear implants, chronic lung or cardiac illness, asthma, a history of smoking, or chronic metabolic disease such as diabetes.

When to refer

When an individualized lifestyle program is needed.

Key messages

Adult vaccination could help reduce morbidity and mortality from VPDs.

Nonhormonal therapy

Learning objectives

To understand the non-HT options.

Nonhormonal therapy

Women with contraindications to MHT, or those who prefer not to use hormones, may choose to use nonhormonal medicines to relieve VMSs. These are not as effective as MHTTo a lesser extent, cognitive-behavioral therapy (CBT) and clinical hypnosis have been shown to reduce VMS effectivelyCBT is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical problem-solving approach.

Pharmacological

The pharmacological agents used are antidepressants and anticonvulsants [Table 12].{Table 13}

Do not prescribe paroxetine and fluoxetine to women taking tamoxifen.

Selection of medication depending on the predominant symptom [Table 13].{Table 14}

Complementary and alternative treatment

Many complementary and alternative treatments are available for managing the symptoms of menopause, but scientific evidence is lackingCommonly studied include plant estrogens (phytoestrogens), bio-identical hormones, yoga, acupuncture, and hypnosisCochrane review (2013) - No conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or severity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates genistein should be further investigated.

When to refer to a specialist

Not responding to therapy.

Key messages

Women with contraindications to MHT, or those who prefer not to use hormones, may choose nonhormonal medicines to relieve of VMSsThese are not as effective as MHT, nor do they have other health benefits of MHT.

Hormone therapy

Learning objective

Terminology of HTTo understand the indications and contraindicationsTo understand the use of MHT for managing symptoms of menopauseBenefits and risks analysisPractical prescription of MHTManagement of conditions related to menopause.

Hormone therapy

The term HT covers therapies including estrogens, progestogens, combined therapies, androgens, and tiboloneHT involves different routes of administration, different potencies, potentially different effects of each molecule, and risks and benefits differ in different individuals and the same individual at different life periodsHT is individualized, and an effective lowest dose is prescribed. Younger women need a larger dose to maintain the benefits of estrogen, and the requirement decreases with aging.

The terminology used in HT is as follows:

MHTHT—MHT and HT are interchangeable and mean the sameHRT, when used as replacement therapy for POIEstrogen therapy (ET)Estrogen-progesterone therapy (EPT)Androgen therapy.Selective estrogen receptor modulator: Raloxifene, bazedoxifeneGonadomimetics: Tibolone, which has an estrogenic, progestogenic, and androgenic activityOral contraceptive pills (OCPs)Combined contraceptiveProgesterone-only pill.

Indications of menopause hormone therapy

Systemic MHT is the most effective treatment for VMSsVaginal estrogen therapy is the most effective option to treat the genitourinary syndromeSystemic MHT is indicated to manage osteoporosis within the first 10 years of menopauseFor treatment of POI, HRT is advised at least until the average age of menopause.

Types of estrogens

The term estrogen (endogenous and exogenous) describes various related chemical compounds that have varying affinities for estrogen receptors present in the bodyThe clinical effects are due to a complex process involving the estrogen receptor complex [Figure 7].Estrogen at an optimum level is needed to maintain estrogen-related benefitsDeficiency or excess of estrogens can lead to problems, as depicted in [Figure 8]The critical determinant of an estrogen preparation's usefulness is its potency and biological effectiveness17 beta-estradiol, estradiol valerate, conjugated equine estrogens (CEEs), estriol, and estetrol are considered natural or native estrogensEthinyl estradiol is grouped under synthetic estrogensAt menopause, the woman needs low potency, and hence, natural estrogens are preferred for menopausal HT and the potent synthetic ethinyl estradiol as an oral contraceptive.{Figure 7}{Figure 8}

Progesterone

The role of progesterone in MHT at menopause is to prevent the proliferation of the endometrium due to estrogen and prevent endometrial hyperplasia and EC.

Route of administration

The route of administration of estrogen depending on the woman's profile and need may be oral, transdermal, vaginal, and progestogen is given by oral, vaginal, or intrauterine placement.

Contraindications to systemic menopausal hormonal therapy

Active or previous breast cancer, EC, and ovarian hormone-dependent cancersKnown or suspected pregnancyUndiagnosed, abnormal vaginal bleedingActive venous thromboembolismSevere active liver disease with impaired or abnormal liver functionAt high risk for CVD, breast cancerInitiation of MHT 10 years postmenopause.

Relative contraindications to systemic menopausal hormonal therapy when transdermal is preferred

Moderate risk for CVDMigraine with auraPrevious personal or family history and at high risk of VTE.

Contraindications to local vaginal estrogen therapy

There are no absolute contraindicationsA relative contraindication is for women with a history of breast or other estrogen-dependent cancer. It is recommended to discuss the proposed vaginal estrogen treatment with the treating oncologist.

Regimens of administering menopausal hormonal therapy

Continuous sequential/cyclic estrogen-progesterone therapy

Estrogen is used every day, with progesterone added cyclically for 10–14 days during each monthUterine bleeding occurs in about 80% of women when progestogen is withdrawn, although bleeding can begin 1–2 days earlier, depending on the type and dose of the progestogen usedIn a typical continuous sequential/cyclic regimen, a progestogen is started on day 1 or day 15 each month.

 Continuous combined estrogen-progesterone therapy



Fixed doses of estrogen and progesterone are administered every dayApproximately 40% incidence of irregular spotting or bleeding in the first 6 months.

How to choose the menopausal hormonal therapy regimens?

 Perimenopausal women



The options available are monthly sequential regimensContinuous combined regimens should not be used in perimenopausal women because of the high risk of irregular bleeding.

Postmenopausal women

Continuous combined therapy is the regimen of choice and induces endometrial atrophy.

Approximately 40% incidence of irregular spotting or bleeding in the first 6 months.

Refer [Table 14] for the dose and type of estrogens used in MHT and [Table 15] for the type and dosage of progesterone used in MHT.{Table 15}{Table 16}

Tibolone is prescribed 1 year after menopause.

Surgical menopause

Estrogen alone without the addition of progesterone may be prescribed or tibolone. Progesterone is added along with estrogens in hysterectomized woman in cases of endometriosis, endometrial ablation, and supracervical hysterectomy.

Refer Annexes for flowchart of menopause care and prescription of MHT.

Premature ovarian insufficiency

OCP or HT may be prescribed till the age of natural menopauseFor cases of the genitourinary syndrome, local estrogen therapy is sufficient.

Risks and benefits of menopausal hormonal therapy

 Risks



MHT and breast cancer

The potential increased risk of breast cancer associated with menopausal MHT is small. With the combined estrogen–progestogen preparations, it is estimated to be an absolute increase of fewer than one case per 1000 women per less than a year of use, that is, 0.1% per yearThis increased risk is like or lower than those associated with common lifestyle factors, such as reduced physical activity, obesity, and alcohol consumptionThere is no evidence of a greater increase in risk with MHT than that observed with MHT in the general population in women at a high risk of breast cancer, even for those with BRCA mutationsMHT does not cause breast cancer and may promote the growth of preexisting cancers that might not have grown otherwise or might have remained too small to be diagnosedThere is no increase in the risk of breast cancer by the use of estrogen alone, as suggested from the evidence in the literature.

MHT and VTE

Oral MHT increases VTE risk by two-fold.In the first year of use, the risk of venous thrombosis increases slightly from 1 per 10,000 to 3 per 10,000; this risk may be lower with transdermal preparationsThe risk of VTE is increased with smoking, increasing age, and obesityTransdermal appears to be safe when needed in women with the normal and at high risk for VTE.

MHT and CVD

HT should not be prescribed for primary or secondary prevention of CVD.However, healthy women within 10 years of menopause tend to have a risk of reduction of CVDThe presence of cardiovascular risk factors is not a contraindication to HRT as long as they are optimally managed.

MHT is not contraindicated in women with hypertension, and in some cases, treatment may even reduce BP.

 Benefits



BoneET/EPT prevents all osteoporotic fractures even in low-risk populationsIt reduces the risk of spine, hip, and other osteoporotic fractures by 33%–40%Lesser colorectal cancersDecrease in the risk for type 2 diabetesDecreases abdominal obesityMay have a protective effect on osteoarthritisEstrogen benefits verbal memory over the short period when initiated soon after surgical menopauseMay reduce the neovascular macular lesionsHT in the early menopausal period improves QOL by its effects on VMSs and urogenital symptoms and improvement on sleep and mood.

Adverse effects

Minor side effects such as breast tenderness, nausea, and leg cramps are common in the first few weeks of MHT treatment.

Side effects related to the progestogen are headaches, irritability, and bloating. These can often be resolved by changing the type or route of progestogen dose.

Follow-up

Review after 1 month for efficacy and side effects, check weight and BP, after 3 months to assess effects and compliance, then annually to include a physical examination, update of medical and family history, relevant laboratory and imaging investigations, a discussion on lifestyle, and strategies to prevent or reduce chronic disease.

General principles for prescribing menopausal hormonal therapy

A full gynecological assessment is mandatory before start MHT and yearly after that.

As described in the chapter in evaluating menopause and annual follow-up, pre-HT clinical and laboratory workup is essential when prescribing MHTMHT is safe in women within 10 years of menopause without contraindications for therapyCounsel on all aspects of menopause and MHT. Evaluate women's needs, preferences, concerns, and individual medical risk factors and benefits before prescribing MHT.The continuous sequential regimen at perimenopause and continuous combined regimen at postmenopauseWoman's Health Initiative trials and other studies support safe to use for at least 5 years in healthy women initiating treatment before 60 years of ageMHT is prescribed in the lowest effective doseNo reasons to place mandatory limitations on the duration of MHT. The treatment is individualizedRisks and benefits of MHT differ for women during the MT compared to those for older womenNot all MHT preparations have the same risk and side effect profile; treatment should be individualized for each patientIn women aged <50 years: The benefits of MHT far outweigh the risks, and MHT should be offered to women aged between 50 and 60 years with menopausal symptomsBenefits of MHT outweigh the risks for women aged >60 years: Benefits of MHT equal the risks, and treatment should be individualizedFor women aged >70, the risks tend to outweigh the benefit.

Summary of management of menopause symptoms and related problems

Management of vasomotor symptoms

Postmenopausal women with mild hot flashes

Simple lifestyle changes such as keeping the core body temperature cool and behavioral and lifestyle modifications are often adequate to manage symptoms and usually do not seek or require pharmacologic intervention.

Postmenopausal women with moderate-to-severe vasomotor symptoms

Lifestyle changes and behavioral modificationIf there is no contraindication to the use of MHT - Low-dose estrogen plus progestin therapy is prescribed to a woman with a uterusEstrogen alone if no uterus.

Postmenopausal women with moderate to severe and who are not candidates for menopause hormone therapy

Lifestyle changes, CBTPredominantly daytime symptoms – Paroxetine as a first-line drugPredominantly nighttime symptoms – Gabapentin.

Management of genitourinary syndrome

Vaginal ET is most effective in the treatment of GSM.

Vulvovaginal atrophy

Nonhormonal lubricants and moisturizers are often recommended to provide short-term relief from mild-to-moderate vaginal dryness and dyspareunia

 Lubricants



Lubricants are specifically designed to reduce friction associated with sexual activity to provide temporary relief from vaginal dryness and dyspareunia. There are two basic types; water and silicone-basedThe WHO recommends that the osmolality of a personal lubricant should not exceed 380 mOsm/kg to minimize any risk (mucosal irritation and tissue damage), which may cause epithelial damage or cytotoxicityWomen prone to yeast infections should avoid glycerin-based lubricants.

 Moisturizers



Vaginal moisturizers are used on a chronic maintenance basis to replace normal vaginal secretionsThey are like natural vaginal secretions, are absorbed locally and adhere to the vaginal mucosa, thus helping to rehydrate dry tissuesThey can be used several times per week, as and when needed, independent of sexual activity.These have comparatively long-term effects than lubricants and can be used simultaneously with other GSM therapeutic agentsBoth types of products can be used in combination with other GSM treatments.

Local estrogen therapy

Early initiation of therapy is indicated to prevent irreversible vaginal atrophy, followed by long-term maintenance therapy.

Lifestyle

Women should be encouraged to have regular sexual activity and vaginal coitus for optimal vaginal health.

Smoking cessation would delay/prevent vaginal atrophy.

Recurrent urinary tract infections

At this age, a woman may benefit from the local application of estrogens when other causes have been ruled out.

General principles for prescribing local menopause hormone therapy

A detailed evaluation or laboratory workup is not a prerequisite before starting therapyEarly initiation of therapy is indicated to prevent irreversible vaginal atrophy, followed by long-term maintenance therapyRegarding dosages, the smallest dose for a short period help for recurrence of atrophic vaginitis, which can be tapered after the acute event to a maintenance dose for long-term benefitIt is recommended not to use ET for more than a year of uninterrupted useIt is safe for use even in women with comorbiditiesProgesterone is not required for endometrial protection with vaginal estrogenLow-dose estrogen therapy does not require endometrial evaluation in low-risk women if asymptomatic – those with irregular bleeding warrant ultrasonography and endometrial biopsy.Vaginal ET reduces symptoms of vulvovaginal atrophy, but it does not alleviate VMS or reduce in risk of osteoporosis VMS as systemic absorption is minimalThere is no elevated risk of CVD or cancer (endometrial, breast, ovarian, colorectal, or hip fracture) with vaginal ET usage. There is minimal systemic absorption. Hence, the standard contraindications for systemic hormone therapy do not apply to vaginal estrogen therapy.

Regimen and dose

Estriol 0.5 mg (0.5 g vaginal cream) or CEE 0.0625 mg (in 1 g vaginal cream) for local application daily for 15 days followed by twice weekly for 1–3 months. The dose can be adjusted from 0.3 mg to 1.25 mg of CEE in 0.5–2 g of cream.

Treating genitourinary syndrome of menopause in women with a history of active or high risk for breast cancer

The initial treatment for all women with breast cancer and breast cancer survivors is the non-HTs.

If women with a history of estrogen-dependent breast cancer are unresponsive to nonhormonal remedies, they also advise using vaginal ET appropriate for these patients, but only after a thorough discussion of risks and benefits.

Sexual dysfunction

Advise the use of lubricants and moisturizersAvoid precipitants that exacerbate vaginal dryness and increase BV incidence and thrush, such as vaginal deodorants or tight, restricted clothingPromote continence by encouraging pelvic floor exercises or referral to continence servicesVaginal ET can be prescribed and used in conjunction with lubricants in case of vulvovaginal atrophySystemic HT is restricted to women with low libido.

Dose

Vaginal estriol succinate cream 0.5 mg or tablet estriol 1 mg, 2 mg or vaginal CEE 0.625mg if urogenital atrophy is presentTibolone 2.5 mg OD ta6 weeks to 3 months for libido.

Management of osteoporosis

The goal is to maintain and prevent bone loss.

Therapeutic lifestyle management

This is an essential part of the management of osteoporosis.It includes a balanced diet, adequate physical activity, and exposure to sunlightAvoidance of bone-depleting agents such as tobacco and alcohol.Low sodium intake: daily salt intake should not exceed 5 g (1 tsp)Protein should be 1 g/kg body weightDecrease caffeine intake (<3 cups/day), limit alcohol, and avoid tobacco use.Maintain calcium and Vitamin D levels.Adequate physical activity is needed to maintain bone health. Appropriate resistance and weight-bearing maintain bone health. Balance exercises times a week for 30 min is part of maintaining health but on its own would not be sufficient for bone healthPatients with severe osteoporosis should avoid engaging in motions, such as forward extension exercises, using heavyweights, or even performing side-bending exercises, because pushing or pulling the spine may lead to fracture.

Prevention of falls

Prevention of falls can decrease the risk of an osteoporotic fracture, particularly of the hip and wrist.

Refer Algorithms 1 and 2 for the management - Refer to Clinical Aids.

Cardiovascular disease

All peri-menopausal women should have an individual CVD risk assessment. Women should receive lifestyle advice where modifiable risk factors are identified (stopping smoking, weight reduction, healthy diet, increased regular exercise).

When to refer

Problems while on MHT.

Key messages

The most effective treatment for vasomotor symptoms is systemic MHTVaginal estrogen therapy is the most effective in treating urogenital atrophy and may be used in women with comorbiditiesSystemic MHT for the management of osteoporosis within the first 10 years of menopauseTreatment for POI, MHT, or OCP, is advised at least until the average age of menopauseThe contraindications to systemic MHT are active or previous breast cancer, EC, and ovarian hormone-dependent cancers. Severe active liver disease with impaired or abnormal liver functionThere are no absolute contraindications to local vaginal estrogen therapyIn a woman with a uterus, unscheduled vaginal bleeding is a common side effect of MHT within the first 3 months of treatment.

Meeta M, Digumarti L, Agarwal N, Vaze N, Shah R, Malik S. Clinical practice guidelines on menopause: *An executive summary and recommendations: Indian Menopause Society 2019-2020. J Midlife Health 2020;11:55-95.Meeta M, Harinarayan CV, Marwah R, Sahay R, Kalra S, Babhulkar S. Clinical practice guidelines on postmenopausal osteoporosis: *An executive summary and recommendations – Update 2019-2020. J Midlife Health 2020;11:96-112.The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause 2017;24:728-53.Baber RJ, Panay N, Fenton A; IMS Writing Group. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric 2016;19:109-50.NICE 2015. Menopause: diagnosis and management. Available from: www.nice.org.uk/guidance/NG23 12 November, 2015.Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV, et al. Treatment of symptoms of the menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015;100:3975-4011.Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: Addressing the unfinished agenda of staging reproductive aging. Menopause 2012;19:387-95.

 Module 5: Tool Kit for Menopause Management



Setting up of a menopause clinic

Aim

The aim is to offer a comprehensive, friendly service under one roof to care for climacteric and geriatric women. Specialized menopause clinics are meant to be dedicated to meet the unique and changing medical needs of women from perimenopause through the golden years.

Level of care

Level I: Primary care unitLevel II: Multidisciplinary unit.

Requirements

Level I: Primary care unitPremises: Waiting area and consultation room

Personnel

Core team: General physician and a paramedicAncillary team: Visiting consultants to be invited

Instruments and equipment: Weight machine, stadiometer, sphygmomanometer, measuring tape, thermometer, the speculum of various sizes, acetic acid, Lugol's iodine, pH sticks, examination table, a light source with provision for lithotomy position, Pap smear kits, HPV kitsStationery

Menopause card, prescription pads, investigation requisition forms, educational charts and leaflets, and computer (optional)Documentation, record keeping, and client recall system are essential to maintain continuity of complete healthcareRelated nonmedical services for esthetic care, hobbies, occupational therapy. Seminars, workshops, a helpline training program for professional education and group activities for women. We need to screen for diabetes mellitus as depicted in [Table 16].{Table 17}

WHO/ISH –HCardiovascular risk prediction chart

WHO/ISH risk prediction charts predict 10-year risk of combined myocardial infarction and stroke risk, fatal and nonfatal have been developed from the best available mortality and risk factor data of these low- and middle-income country populations.

At present, these charts are necessarily crude but are simple, safe, and useful tools for guiding the management and treatment decisions for individuals.

The charts can have an impact on the prevention of heart attacks and stroke, particularly if they can be used by health workers in primary health care.

When are the charts useful for stratifying risk?

Charts are useful for stratifying risk for people with BP <160/100 mmHg or blood cholesterol <8 mmol/l or uncomplicated diabetes.

An individual is classified as high, medium, or low risk over 10 years.

The following come under the high-risk category, no risk assessment, they need to be treated

Persistent raised BP ≥160/100 mmHg or blood cholesterol ≥8 mmol/l or established ischemic heart disease, or diabetes with renal disease.

Note that CVD risk may be higher than indicated by the charts in the presence of the following

Already on antihypertensive therapy, premature menopause, obesity (including central obesity); sedentary lifestyle; family history of premature CHD or stroke in first-degree relative (male <55 years, female <65 years); raised levels of C-reactive protein, microalbuminuria (increases the 5-year risk of diabetics by about 5%).

There are two sets of charts.

One set can be used in settings where blood cholesterol cannot be measured.Second set is for settings in which blood cholesterol can be measured Refer charts 1,2,3,4.

How do you use the charts to assess cardiovascular risk?

First make sure that you select the appropriate chartIf blood cholesterol cannot be measured due to resource limitations, use the charts that do not have total cholesterolBefore applying the chart to estimate the 10-year cardiovascular risk of an individual, the following information is necessary

Presence or absence of diabetesGenderSmoker or non-smokerAgeSystolic BPTotal blood cholesterol (if in mg/dl, divide by 38 to convert to mmol/l).

Once the above information is available, proceed to estimate the 10-year cardiovascular risk.

Step 1 Select the appropriate chart depending on the presence or absence of diabetesStep 2 female tablesStep 3 Select smoker or nonsmoker boxesStep 4 Select age group box (if age is 50–59 years, select 50; if 60–69 years, select 60; etc.)Step 5 Within this box, find the nearest cell where the individual's systolic BP (mmHg) and total blood cholesterol level (mmol/l) 4 cross.

The color of this cell determines the 10-year cardiovascular risk.

An individual is classified as high risk (maroon and red), medium risk (orange and yellow), or low risk (green) over 10 years, [Table 17]{Table 18}

WHO/ISH risk prediction charts for India:

10-year risk prediction chart for CVD events by gender, age, systolic BP, smoking status, and presence or absence of diabetes mellitus

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10-year risk prediction chart for CVD events by gender, age, systolic BP, smoking status, cholesterol, and presence or absence of diabetes mellitus.

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Risk assessment for breast cancer

The Breast Cancer Risk Assessment Tool, Gail Model allows health professionals to estimate a woman's risk of developing invasive breast cancer over the next 5 years and up to age 90 (lifetime risk) [Table 18].{Table 19}

The tool uses a woman's personal medical and reproductive history and the history of breast cancer among her first-degree relatives (mother, sisters, and daughters) to estimate absolute breast cancer risk—her chance or probability of developing invasive breast cancer in a defined age interval.

It needs to be validated in India. This simple tool may be used in the absence of country-specific validated tool (available from: https://www.cancer.gov/bcrisktool) and classifies the women into three groups.

Breast self-examination

BSE is performed by the woman herself and involves examination of the breast, skin, and axillae based on palpations by her hands. BSE is recommended so that women understand their breasts for detecting any suspicious changes over time [Figure 9].{Figure 9}

BSE should be done immediately after periods or any fixed day of the month if there is not menstruating. Nodular and lumpy feel of the breast and increased pain and tenderness, which is a physiological finding before menstruation, needs to be explained to the patient.

Women can be taught to examine the breasts in any of the following ways in both supine and standing positions.

[INLINE:11]

Osteoporosis screen

WHO developed the osteoporosis self-assessment tool for Asians (OSTA) score a risk assessment tool based simply on age and body weight to identify the women at risk for osteoporosis.

The OSTA is calculated using the following formula: (body weight [kg] − age [years]) × 0.2, with the decimal digits being disregarded or the chart below may be used.

Women are stratified into three groups at risk for sustaining osteoporosis [Table 19]{Table 20}

Recommendation based on risk

High-risk patients: to measure BMD, if possible, and consider drug treatment even if BMD if not available (about 61% of individuals in the high-risk group have osteoporosis.)Moderate-risk patients: to measure BMD and consider drug treatment if BMD is low (about 15% of individuals in the moderate-risk group have osteoporosis)Low-risk patients: Not to measure BMD unless other risk factors are present (only about 3% of individuals in the low-risk group have osteoporosis).

Fracture Risk Assessment Tool (FRAX): It is country-specific and an online tool available for India (http:www.shef.ac.uk/FRAX). FRAX is used to identify patients in the osteopenia group most likely to benefit from treatment. It predicts the 10-year absolute risk for a fracture in an individual and the cost-effective analysis determines the interventional threshold above which treatment is cost-effective. FRAX is country-specific, and until more Indian data are available on the prevalence of osteoporotic fractures and mortality rates, it may not serve the true purpose for the usage of FRAX in the Indian context.

10-year absolute risk for a fracture in an individual to decide for treatment [Table 20]{Table 21]

Sarcopenia screening

European Working Group on Sarcopenia in Older People (EWGSOP) advises use of the SARC-F questionnaire or clinical suspicion to find sarcopenia-associated symptoms.

Screen by history: A case-finding strategy starts when a patient reports symptoms or signs of sarcopenia, i.e., falling, feeling weak, slow walking speed, difficulty rising from a chair or unintentional weight loss/muscle wastingIn such cases, testing for sarcopenia is recommended by using SARC-F questionnaire, SARC-F is a self-administered questionnaire, which has five components including strength, assistance in walking, rise from a chair, climb stairs, and falls with a 3-level score range of 0 to 2 points for each item [Table 21]SARC-F is an inexpensive and convenient method for sarcopenia risk screeningSARC-F has a low-to-moderate sensitivity and a very high specificity to predict low muscle strength.{Table 22}

SARC-F score

The total score range is from 0 to 10, with scores of 0 stairs? ? ty to predict low muscle strengthseAssess for evidence of sarcopenia: EWGSOP recommends use of grip strength or a chair stand measure with specific cut-off-points for each test.EWGSOP2 sarcopenia cut-off points for low strength by chair stand and grip strength

Grip strength <16 kgChair stand >15 s for five rises.

Methods

Grip strength-handgrip strength is the most widely used method for the measurement of muscle strength.

Time of administration: 5 minEquipment: A well-calibrated handheld dynamometerMethods: Six measures should be taken, 3 with each arm. Ideally, the patients should be encouraged to squeeze as hard and as tightly as possible during 3–5 s of the measure, the highest reading of the 6 measurements is reported as the final result.

Chair stand test

The chair stand test (also called chair rise test) can be used as a proxy for strength of leg muscles (quadriceps muscle group).

Time of administration: 1–2 minEquipment: A chair with a straight back without arm rests and a stopwatchMethod: The subject is first asked to stand from a sitting position without using their arms. If he/she is able to perform the task, he/she is then asked to stand up and sit down five times, as quickly as possible with arms folded across their chests. The time to complete five stands is recorded. The chair stand test measures the amount of time needed for a patient to rise five times from a seated position without using his or her arms.

 Annexures



Annexure 1: Midlife Health Card

A pro forma for an initial assessment and follow-up is ideal to maintain the record of the health of the midlife woman.

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Investigations:

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Impression: Healthy with no problems/healthy with menopausal symptoms/healthy with risk factor/healthy with latent disease/medically compromised.

Plan of Management:

 Annexure 2: Menopause Rating Scale



Menopause rating scale (MRS) is used to document the degree of severity consistent with menopausal symptoms in terms of percentage at the initial and follow-up visits. It also reflects the effectiveness of therapy

Symptoms: Menopause symptom rating scale

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According to WHO standard, the degree of severity are consistent with:

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Description of the symptoms of MRS

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 Annexure 3: Algorithm for Menopause Management



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 Annexure 4: Flow Chart For Initiation of Prescription Of Menopausal Hormone Therapy(MHT) If age < 60 yrs or menopause < 10 years



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 Annexure 5: Algorithm for Management of Osteoporosis



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 Annexure 6: DRUG CHART



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 Annexure 7: Algorithm for Management of Sarcopenia



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