ABSTRACT
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
- 1Women who initiate menopausal hormone therapy shortly after menopause are, in general, at low risk for events in the next few years (high). Evidence supports aggressive identification and modification of risk factors as the most effective means of reducing cardiovascular risk (high).
- 2Women who initiate menopausal hormone therapy 10 or more years after menopause are at increased risk for adverse cardiac events (high).
- 3With respect to stroke, increased risk has been identified in all age groups using standard formulations of menopausal hormone therapy; however, the incidence in young women is extremely low (low).
- 4Incidence of venous thrombotic events increase with age (> 60 y) and BMI, even in otherwise healthy women; menopausal hormone therapy increases the risk (high).
- 5Menopausal hormone therapy is not indicated for primary or secondary prevention of cardiovascular disease (moderate).
- 6Women with premature or early-onset menopause appear to be at an increased risk of adverse cardiovascular outcomes, and this risk may be prevented by the use of menopausal hormone therapy until the average age of menopause (moderate).
- 7Menopausal hormone therapy increases the risk of venous thromboembolism; oral and combined hormone therapy preparations are more closely associated with risk of venous thromboembolism than either with transdermal preparations or estrogen alone (moderate).
- 8There is a lack of high-quality data to provide guidance on the impact of routes of estrogen administration on the risk of venous thrombotic events or cardiovascular disease (low).
RECOMMENDATIONS
- 1Menopausal hormone therapy should be offered as the most effective treatment for the relief of menopausal symptoms (strong, high).
- 2When prescribing menopausal hormone therapy, the lowest effective dose of estrogen, and, where indicated, estrogen-only therapy, should be offered to minimize the associated risk of venous thromboembolism (conditional, low).
- 3The lowest effective dose of estrogen, either oral or transdermal, should be prescribed to minimize the risk of stroke (conditional, low).
- 4When prescribing combined hormone therapy, choice of progestogen should favour those least likely to affect markers for cardiovascular disease. (strong, moderate).
- 5A tissue selective estrogen complex may be used without a progestin to provide menopausal hormone therapy and uterine protection for relief of early menopausal symptoms (conditional, moderate). To date, these agents do not appear to be associated with cardiovascular risk.
Keywords
Abbreviations:
CVD (cardiovascular disease), DOPS (Danish Osteoporosis Prevention Study), ELITE (Early Versus Late Intervention Trial With Estradiol), KEEPS (Kronos Early Estrogen Prevention Study), MHT (menopausal hormone therapy), SERM (selective estrogen receptor modulator), SMART (Selective estrogens, Menopause and Response to Therapy), VTE (venous thromboembolism), WHI (Women's Health Initiative)To read this article in full you will need to make a payment
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REFERENCES
- Hormone therapy for preventing cardiovascular disease in post-menopausal women.Cochrane Database Syst Rev. 2015; CD002229
- Menopausal hormone therapy and national time trends in mortality: Cautions regarding causal inference.Menopause. 2017; 24: 874-876
- Arterial imaging outcomes and cardiovascular risk factors in recently menopausal women: A randomized trial.Ann Intern Med. 2014; 161: 249-260
- Vascular effects of early versus late postmenopausal treatment with estradiol.N Engl J Med. 2016; 374: 1221-1231
- Methods and baseline cardiovascular data from the early versus late intervention trial with estradiol testing the menopausal hormone timing hypothesis.Menopause. 2015; 22: 391-401
- Changes in carotid artery intima-media thickness 3 years after cessation of menopausal hormone therapy: Follow-up from the kronos early estrogen prevention study.Menopause. 2019; 26: 24-31
- Hormone therapy for the primary prevention of chronic conditions in postmenopausal women: Us preventive services task force recommendation statement.JAMA. 2017; 318: 2224-2233
- Association of age at onset of menopause and time since onset of menopause with cardiovascular outcomes, intermediate vascular traits, and all-cause mortality: A systematic review and meta-analysis.JAMA Cardiol. 2016; 1: 767-776
- Impaired endothelial function in young women with premature ovarian failure: Normalization with hormone therapy.J Clin Endocrinol Metab. 2004; 89: 3907-3913
- The association between early menopause and risk of ischaemic heart disease: Influence of hormone therapy.Maturitas. 2006; 53: 226-233
- The 2017 hormone therapy position statement of the north american menopause society.Menopause. 2017; 24: 728-753
- Identifying and managing younger women at high risk of cardiovascular disease.CMAJ. 2019; 191: E159-EE63
- Cardiovascular safety of conjugated estrogens plus bazedoxifene: Meta-analysis of the smart trials.Climacteric. 2015; 18: 503-511
- Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: Randomised trial.BMJ. 2012; 345: e6409
- Use of hormone replacement therapy and risk of venous thromboembolism: Nested case-control studies using the qresearch and cprd databases.BMJ. 2019; 364: k4810
- Treatment of symptoms of the menopause: An endocrine society clinical practice guideline.J Clin Endocrinol Metab. 2015; 100: 3975-4011
- Short-term and long-term effects of tibolone in postmenopausal women.Cochrane Database Syst Rev. 2016; 10CD008536
- Cholesterol lowering in intermediate-risk persons without cardiovascular disease.N Engl J Med. 2016; 374: 2021-2031
- Effect of aspirin on cardiovascular events and bleeding in the healthy elderly.N Engl J Med. 2018; 379: 1509-1518
- Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (arrive): A randomised, double-blind, placebo-controlled trial.Lancet. 2018; 392: 1036-1046
Article info
Publication history
Published online: November 16, 2021
No. 422e, December 2021 (Replaces No. 311, September 2014)Footnotes
This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care providers. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that is evidence-based, culturally appropriate, and personalized.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women's health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person's needs.
Identification
Copyright
© 2021 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
