Managing Menopause

1. Age and menopausal stage — premenopausal, perimenopausal (irregular cycles), or postmenopausal (12 months amenorrhea)? Age at menopause? (Default: from history)
2. Symptom inventory — VMS (hot flashes, night sweats), GSM (vaginal dryness, dyspareunia, urinary symptoms), mood changes, sleep disturbance, cognitive complaints? (Default: use structured assessment)
3. Menstrual history — LMP, cycle changes, bleeding pattern in perimenopause? (Default: from history)
4. HT contraindications — breast cancer (current or history), coronary heart disease, stroke/TIA, active VTE, active liver disease, undiagnosed vaginal bleeding? (Default: from problem list)
5. Risk factors — VTE history, family history of breast cancer, BMI, tobacco use, cardiovascular risk factors? (Default: from chart)
6. Bone density — DXA results, fracture history, fall risk? (Default: from prior testing)
7. Prior HT use — type, duration, reason for discontinuation? (Default: from medication history)
8. Surgical history — hysterectomy (with or without BSO)? Oophorectomy age? (Default: from surgical history)

Documents to Request

• Symptom severity questionnaire (MRS — Menopause Rating Scale, or Greene Climacteric Scale)
• DXA bone density report
• Mammogram results (within 1 year)
• Lipid panel and cardiovascular risk assessment
• FSH level (if diagnostic uncertainty in perimenopause or POI evaluation)
• Endometrial evaluation results (if applicable — for abnormal bleeding workup)
• Prior HT prescriptions and response

Step 1: Confirm Menopausal Status

For POI: pursue karyotype (rule out Turner mosaicism), adrenal antibodies (21-hydroxylase), thyroid function, and consider FMR1 premutation screening.

Step 2: Assess Symptom Severity and Treatment Need

Vasomotor Symptoms (VMS) Severity Scale

Document frequency (episodes per day/week), duration (average length), and impact on sleep and daily function.

Genitourinary Syndrome of Menopause (GSM)

• Vaginal dryness, burning, irritation
• Dyspareunia (pain with intercourse)
• Urinary urgency, frequency, recurrent UTIs
• Reduced lubrication and elasticity on exam

GSM is progressive and does not improve without treatment. Low-dose vaginal estrogen is the first-line therapy and has minimal systemic absorption.

Step 3: Evaluate HT Candidacy

Indications for Systemic HT (per NAMS 2022)

• Bothersome VMS in women < 60 years old or within 10 years of menopause onset
• Prevention of osteoporosis when other therapies are not appropriate
• POI (HT recommended until the average age of natural menopause — 51)

Absolute Contraindications to Systemic HT

• Current or recent breast cancer
• Coronary heart disease
• History of stroke or TIA
• Active VTE or known high-risk thrombophilia
• Active liver disease
• Unexplained vaginal bleeding (evaluate before starting HT)

Relative Contraindications Requiring Individual Assessment

• Family history of breast cancer (first-degree relative)
• History of endometrial cancer (estrogen-dependent type)
• Gallbladder disease
• Migraine with aura
• Hypertriglyceridemia (> 400 mg/dL — avoid oral estrogen; transdermal preferred)

Document the risk-benefit discussion with the patient, including baseline breast cancer risk (use the Gail Model or Tyrer-Cuzick model).

Step 4: Select HT Regimen

Systemic HT Options

Non-Hormonal Alternatives for VMS

• Fezolinetant (Veozah) — neurokinin 3 receptor antagonist; FDA-approved for VMS
• Paroxetine 7.5 mg (Brisdelle) — only FDA-approved SSRI for VMS
• Venlafaxine 75 mg — off-label but effective for VMS
• Gabapentin 300 mg TID — effective for nocturnal VMS
• Clonidine 0.1 mg — modest effect, useful if other agents contraindicated
• CBT and clinical hypnosis — evidence-based non-pharmacologic options

Step 5: Monitoring and Duration of Therapy

• Reassess symptoms and risks annually
• Mammogram annually while on systemic HT
• For women with a uterus on HT: evaluate any unscheduled bleeding with transvaginal ultrasound and/or endometrial biopsy
• Use the lowest effective dose for the shortest duration that meets treatment goals
• No mandatory time limit for HT — individualized decision based on ongoing risk-benefit assessment
• Taper rather than abrupt discontinuation to reduce symptom rebound (reduce dose by 50% for 3–6 months)

Bone Health

• DXA screening: age 65 (all women), or earlier if risk factors (glucocorticoid use, family history, low BMI, POI)
• If HT is being used partly for bone protection, ensure alternative osteoporosis therapy is in place before discontinuing HT

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is menopausal status clearly defined — natural, surgical, or POI with age at onset?
2. Are symptoms documented with severity and functional impact?
3. Are contraindications to HT screened and documented?
4. Is the risk-benefit discussion documented with patient-specific considerations?
5. Is the HT regimen specified — route, dose, progestogen component (if uterus intact), and duration plan?

Quality Audit

• Menopausal status confirmed with method (clinical, laboratory, surgical)
• VMS severity documented with frequency and functional impact
• GSM symptoms assessed and documented
• Absolute contraindications to HT screened and documented
• Breast cancer risk assessment performed (Gail Model or equivalent)
• Mammogram within 1 year documented before initiating HT
• HT regimen documented with route, dose, and progestogen plan
• Progestogen included for all women with intact uterus on systemic estrogen
• Duration plan documented with annual reassessment scheduled
• Non-hormonal alternatives discussed if HT contraindicated or declined
• Bone density assessment addressed (DXA ordered or on file)
• Cardiovascular risk factors documented
• POI patients counseled on HT to average menopause age (51) for cardio/bone protection
• Informed consent documented including WHI data in context

Guidelines

1. Apply the timing hypothesis — systemic HT is safest when initiated within 10 years of menopause onset or before age 60; starting after this window increases cardiovascular risk.
2. Always add progestogen when prescribing systemic estrogen to a patient with a uterus — unopposed estrogen causes endometrial hyperplasia and cancer.
3. Prefer transdermal estrogen in patients with VTE risk factors, hypertriglyceridemia, or migraine — it avoids first-pass hepatic metabolism and does not increase VTE risk to the same degree as oral estrogen.
4. Vaginal estrogen does not require progestogen — low-dose vaginal preparations have minimal systemic absorption and are safe even in many breast cancer survivors (though oncologist consultation is recommended).
5. POI is not the same as normal menopause — these patients need HT for cardiovascular and bone protection, not just symptom relief, and should continue until age 51.
6. Document the WHI in context — the WHI studied older women (mean age 63) initiating HT remotely from menopause; its findings do not directly apply to symptomatic younger women.
7. Reassess annually — HT is not indefinite by default; document the ongoing indication at every annual visit.