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Directive clinique no 422a : Ménopause : symptômes vasomoteurs, agents thérapeutiques d'ordonnance, médecines douces et complémentaires, nutrition et mode de vie

      RÉSUMÉ

      Objectif

      Proposer des stratégies pour améliorer les soins aux femmes ménopausées ou en périménopause d'après les plus récentes données probantes publiées.

      Population cible

      Femmes ménopausées ou en périménopause.

      Bénéfices, risques et coûts

      La population cible bénéficiera des plus récentes données scientifiques publiées que leur communiqueront les fournisseurs de soins de santé. Aucun coût ni préjudice ne sont associés à cette information, car les femmes seront libres de choisir parmi les différentes options thérapeutiques offertes pour la prise en charge des symptômes et morbidités associés à la ménopause, y compris l'abstention thérapeutique.

      Données probantes

      Les auteurs ont interrogé les bases de données PubMed, Medline et Cochrane Library pour extraire des articles publiés entre 2002 et 2020 en utilisant des termes MeSH spécifiques à chacun des sujets abordés dans les 7 chapitres.

      Méthodes de validation

      Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d’évaluation, de développement et d’évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles).

      Professionnels concernés

      médecins, y compris gynécologues, obstétriciens, médecins de famille, internistes, urgentologues; infirmières, y compris infirmières autorisées et infirmières praticiennes; pharmaciens; stagiaires, y compris étudiants en médecine, résidents, moniteurs cliniques; et autres fournisseurs de soins auprès de la population cible.

      DÉCLARATIONS SOMMAIRES

      • 1
        La vaste majorité des femmes autour de la cinquantaine éprouvent des symptômes ménopausiques, les plus typiques étant les symptômes vasomoteurs. Une proportion importante de ces femmes éprouvent des symptômes sévères qui nuisent considérablement à leur qualité de vie (élevée).
      • 2
        Le traitement hormonal de la ménopause est l'option la plus efficace pour la prise en charge des symptômes vasomoteurs; il peut être instauré en toute sécurité chez les femmes de moins de 60 ans ou ménopausées depuis moins de 10 ans en l'absence de contre-indications (élevée).
      • 3
        Les options de traitement hormonal de la ménopause pour la prise en charge des symptômes vasomoteurs chez les femmes ayant un utérus sont l'hormonothérapie combinée (traitement œstroprogestatif), les complexes œstrogéniques à action tissulaire sélective ou la tibolone. L’œstrogène seul peut être utilisé chez les femmes ayant subi une hystérectomie (élevée).
      • 4
        L'innocuité et l'efficacité de l'hormonothérapie à base d'hormones bio-identiques n'ont pas été évaluées avec la même rigueur que pour les produits de traitement hormonal de la ménopause approuvés par Santé Canada (moyenne).
      • 5
        Les traitements non hormonaux d'ordonnance, tels que certains agents antidépresseurs, les gabapentinoïdes, la clonidine et l'oxybutynine, peuvent offrir un certain soulagement pour les bouffées de chaleur, mais ont leurs propres effets indésirables (moyenne).
      • 6
        De nouvelles données probantes suggèrent que la thérapie cognitivo-comportementale peut avoir des effets positifs sur les symptômes vasomoteurs (élevée).
      • 7
        Les données probantes sont insuffisantes pour appuyer l'efficacité de tout produit naturel pour la prise en charge des bouffées de chaleur modérées à sévères (faible).
      • 8
        L'adoption d'une alimentation saine durant la ménopause peut réduire le risque de problèmes de santé chroniques ultérieurs, favoriser la gestion du poids et augmenter le niveau d’énergie (élevée).

      RECOMMANDATIONS

      • 1
        Les fournisseurs de soins de santé doivent offrir le traitement hormonal de la ménopause comme étant l'option thérapeutique la plus efficace pour la prise en charge des symptômes vasomoteurs (forte, élevée).
      • 2
        Le traitement hormonal de la ménopause peut être instauré en toute sécurité chez les femmes de moins de 60 ans ou ménopausées depuis moins de 10 ans en l'absence de contre-indications (forte, élevée).
      • 3
        Le traitement hormonal de la ménopause doit être individualisé après une analyse attentive des symptômes, de l’état de santé, des risques pour la santé, des antécédents familiaux, des objectifs thérapeutiques, des préférences de la patiente et du moment de la dernière menstruation (forte, élevée).
      • 4
        La durée du traitement hormonal de la ménopause devrait être adaptée à la patiente, en fonction des symptômes persistants, des bienfaits continus et des risques personnels. Il est recommandé de réévaluer périodiquement le traitement hormonal de la ménopause (forte, élevée).
      • 5
        Chez les femmes ayant connu une perte ou une diminution de la fonction ovarienne avant 45 ans, il y a lieu d'envisager une hormonothérapie substitutive jusqu’à l’âge moyen de la ménopause (forte, élevée).
      • 6
        Les schémas de l'hormonothérapie combinée (traitement œstroprogestatif) peuvent être continus (traitement œstroprogestatif quotidien) ou cycliques (œstrogénothérapie quotidienne avec prise de progestatifs pendant 12 à 14 jours chaque mois). L’œstrogénothérapie quotidienne est indiquée chez les femmes ayant subi une hystérectomie (forte, élevée).
      • 7
        Pour les femmes en périménopause, les options sont l’œstrogénothérapie, la contraception hormonale combinée à faible dose, le traitement hormonal de la ménopause ou l’œstrogénothérapie en combinaison avec un système intra-utérin à libération de lévonorgestrel (forte, moyenne).
      • 8
        Il y a lieu d'envisager les traitements non hormonaux d'ordonnance lorsque l'hormonothérapie est contre-indiquée ou n'est pas souhaitée (forte, moyenne).
      • 9
        Il convient d'offrir aux femmes qui souhaitent un traitement traditionnel propre à leur culture l'occasion d’être accompagnée par un leader culturel. Les fournisseurs de soins de santé devraient discuter de cette possibilité avec les patientes afin d'assurer l'humilité et la sécurisation culturelles (forte, moyenne).

      Mots clés

      ABRÉVIATIONS:

      HT (Hormonothérapie), TCC (thérapie cognitivo-comportementale), DHEA (déhydroépiandrostérone), SGUM (syndrome génito-urinaire de la ménopause), SIU-LNG (système intra-utérin à libération de lévonorgestrel), THM (traitement hormonal de la ménopause), PSN (produit de santé naturelle), MSRE (modulateurs sélectifs des récepteurs œstrogéniques), IRSN (inhibiteur du recaptage de la sérotonine et de la noradrénaline), ISRS (inhibiteur sélectif du recaptage de la sérotonine), TSEC (complexes œstrogéniques à action tissulaire sélective), RO (récepteur œstrogénique), SVM (symptômes vasomoteurs)
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