Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1The vast majority of women in mid-life experience menopausal symptoms, the hallmark being vasomotor symptoms. A significant portion of these women have severe symptoms that greatly affect their quality of life (high).2For the management of vasomotor symptoms, menopausal hormone therapy is the most effective option and can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (high).3Options for menopausal hormone therapy for vasomotor symptoms in women with a uterus include estrogen-progestogen therapy, a tissue-selective estrogen complex, or tibolone. Estrogen alone can be used in women who have had a hysterectomy (high).4The safety and efficacy of compounded bioidentical hormone therapy have not been assessed with the same rigour as those of menopausal hormone therapy products approved by Health Canada (moderate).5Non-hormonal prescription therapies, including certain antidepressant agents, gabapentinoids, clonidine, and oxybutynin, may offer some relief from hot flashes but have their own adverse effects (moderate).6There is emerging evidence that cognitive behavioural therapy may have positive effects on vasomotor symptoms (high).7There is insufficient evidence to support the effectiveness of any one natural health product for the management of moderate to severe hot flashes (low).8A healthy diet during menopause can reduce the risk of future chronic conditions, aid in weight management, and improve energy levels (high). RECOMMENDATIONS 1Health care providers should offer menopausal hormone therapy as the most effective option for managing vasomotor symptoms (strong, high).2Menopausal hormone therapy can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (strong, high).3Menopausal hormone therapy should be individualized after careful consideration of symptoms, medical conditions, health risks, family history, treatment goals, patient preferences, and timing of last menstrual period (strong, high).4Duration of menopausal hormone therapy should be individualized to the patient, based on ongoing symptoms, benefits, and personal risks. Periodic re-evaluation of menopausal hormone therapy is recommended (strong, high).5Women who have experienced loss of ovarian function or with decreased ovarian function before the age of 45 years should consider replacement hormone therapy until the average age of menopause (strong, high).6Estrogen-progestogen regimens can be continuous (i.e., estrogen-progestogen taken every day) or follow a cyclic regimen, with estrogen taken every day and progestogen taken for 12–14 days every month. In women with hysterectomy, estrogen alone can be taken every day (strong, high).7Options for perimenopausal women include progestogen alone, low-dose combined hormonal contraceptives, menopausal hormone therapy, or estrogen in combination with a levonorgestrel-releasing intrauterine system. (strong, moderate)8Non-hormonal prescription therapies can be considered when hormone therapy is contraindicated or not desired (strong, moderate).9For cultural traditional therapies, women should be offered the opportunity to work with a cultural leader; health care providers can discuss this option in partnership with women, in order to ensure cultural humility and cultural safety (strong, moderate).