“The 2020 Menopausal Hormone Therapy Guidelines”: Links And Excerpts With Links To Additional Resources

In this post, I link to and excerpt from The 2020 Menopausal Hormone Therapy Guidelines [PubMed Abstract] [Full-Text HTML] [Full-PDF]. J Menopausal Med. 2020 Aug;26(2):69-98. doi: 10.6118/jmm.20000.

There are 82 similar articles in PubMed Central.

The above article has been cited nine times.

All that follows is from the above article.

1. Examinations required prior to receiving MHT

Key points: Examinations required prior to receiving MHT

• 1. The examinations required to be conducted prior to MHT are history taking, physical examination, and examinations for liver function, kidney function, anemia, fasting blood sugar, and blood tests of serum lipid profile, followed by mammography, BMD test, and Pap smear screening.
• 2. The elective examinations required to be conducted prior to MHT are thyroid function test, breast ultrasonography, and endometrial biopsy conducted as individualized tests according to individual risk factors. Depending on clinical manifestation and individual risk factors, the basic examinations and elective examinations are conducted at an interval of 1–2 years.

2. MHT for women in menopausal transition

Menopausal transition refers to the period from the moment of increased variation in menstrual cycle until the moment immediately prior to the last day of menstruation.

Undergoing treatment for menopausal transition should be primarily decided according to the frequency and severity of the symptoms of menopause. Even in the case of menstruation, if a severe hot flush is experienced, a consultation is advised in order to discuss the necessary treatment to improve symptoms [4].

Hormone therapies for treating the symptoms of menopause during menopausal transition are combination therapy of levonorgestrel releasing-intrauterine system (LNG-IUS) with oral or percutaneous estrogen, low-dose combined oral contraceptives (COCs), and estrogen–progestogen therapy (EPT) [4].

EPT is effective not only for treating women after menopause but also for controlling the symptoms of menopause in women in menopausal transition. However, the dose used in general MHT is very low compared with that used for treating women before menopause, and consequently, breakthrough bleedings could frequently occur. If contraception is simultaneously needed, the use of low-dose COCs is recommended. Low-dose COCs are effective for controlling irregular bleeding and alleviation of symptoms of hot flush [4].

In the case of using low-dose COCs, because the symptoms of menopause could worsen during the 7-day pill-free period, the use of continuous COCs or COCs such as Qlaira® with a shorter pill-free period is recommended. With regard to the safety of low-dose COCs, if there are no risk factors involved such as obesity, smoking, high blood pressure, and other cardiovascular diseases, it may be used carefully from 40 to 55 years of age. However, careful screening of each individual’s risk factors is important [5,6,7].

The use of oral or percutaneous estrogen therapy (ET) together with LNG-IUS is not only effective for alleviating the symptoms of menopause but also for preventing endometrial hyperplasia. Even in the case of a normal menstrual cycle, if the symptoms of menopause are severe, the use of a combination therapy of low-dose percutaneous estrogen and LNG-IUS could effectively control a hot flush [8]. In addition, some reports have shown that it could help improve symptoms that appear during menopausal transition such as depression, reduced quality of sleep, and increased anxiety [9,10].

However, as mentioned earlier, it remains unclear how ET initiated at this stage would affect cardiovascular diseases and breast cancer in the long term. Therefore, treatment during the menopausal transition period should be primarily based on the frequency and severity of the symptoms, and different treatment methods should be applied to improve symptoms according to the individual’s risk factors [11].

Key points: MHT for women in menopausal transition

• 1. It is advised not to conduct a hormone test to diagnose menopause during menopausal transition.
• 2. Hormone therapy during menopausal transition should primarily be conducted based on the frequency and severity of symptoms, and lifestyle adjustments and use of adjuvant therapy could be partially effective.
• 3. EPT, low-dose COCs, and combination therapy of LNG-IUS with oral or percutaneous estrogen could be employed as individualized treatments depending on individual risk factors for the purpose of improving symptoms.

3. Vasomotor symptoms and quality of life

3-1. Vasomotor symptoms

Hot flush, a common VMS, suddenly appears in the face and the upper body and spreads to the rest of the body. It usually lasts for approximately 2–4 minutes. Anxiety, shivering, palpitation, or perspiration may occur alongside, and night sweat is linked to sleep disorder.

In terms of the degree of improvement of VMS according to dose, a placebo showed 20%–40% reduction of symptoms, and the effect of extreme low-dose therapy, low-dose therapy, and standard-dose therapy in alleviating symptoms was 55%, 60%–70%, and 80%–90%, respectively, in MHT [19,20,21].

In terms of the degree of improvement of VMS for non-hormonal therapies, selective serotonin receptor inhibitor (SSRI)/selective norepinephrine receptor inhibitor (SNRI) showed 40%–65%, gabapentin (900 mg/day) showed 50%, and pregabalin (150 mg/day) showed 65% improvement of symptoms [22,23].

Progestogen (medroxyprogesterone acetate [MPA] 10 mg/day, oral megestrol acetate 20 mg/day, and MP 300 mg/day) is known to alleviate VMS with a minimal risk, and it is highly effective in the case of severe VMS. The symptoms are less likely to recur when progestogen therapy is discontinued compared with the discontinuation of estrogen therapy [23,24].

In the case of MHT discontinuation, a report showed that VMS recurred at 50% and at most 87%; nonetheless, the severity of VMS in the case of recurrence was not as bad as that before starting MHT [25]. There is no difference in the recurrence rate of symptoms whether MHT is suddenly or gradually discontinued by eventually reducing the dose [2].

Key points: Vasomotor symptoms and quality of life

1. Because VMS appear in relation to the reduction of estrogen levels in the central nervous system, MHT is the most effective treatment.
2. VMS are the main indications of MHT.
3. Apart from VMS, MHT can treat other menopause symptoms such as sleep disorder, depression, and musculoskeletal pain and enhance the overall QoL of women in menopause.
4. MHT is not associated with increased weight; conversely, it helps improve the accumulation of abdominal fat.
5. There is a tendency for symptoms to recur when therapy is discontinued.

There is much more in this article to review and so I remind myself and my readers to review the complete article: The 2020 Menopausal Hormone Therapy Guidelines [PubMed Abstract] [Full-Text HTML] [Full-PDF]. J Menopausal Med. 2020 Aug;26(2):69-98. doi: 10.6118/jmm.20000.

I have included just the key points from here on in.

4. Urogenital atrophy and sexual dysfunction

Key points: Urogenital atrophy

• 1. Urogenital atrophy has been newly renamed as GSM*, which includes all the symptoms caused by changes in the contraction of the bladder, urethra, vagina, and genitalia due to the decreased estrogen level during menopause and vaginal atrophy.
• 2. The use of topical estrogen is recommended for the treatment of GSM and recurrent UTIs.
• 3. Lubricants, vaginal moisturizers, ospemifene, and vaginal DHEA are non-estrogen therapies available for treating urogenital atrophy, but laser therapy could be considered an additional therapy.
• 4. For menopausal women with symptoms of an overactive bladder, the primary drug therapy is the combination therapy of an antimuscarinic drug and topical estrogen.
• 5. Systemic ET is effective for treating vaginal atrophy but not effective for treating recurrent UTIs, overactive bladder, and urinary incontinence.

*GSM-Genitourinary Syndrome of Menopause (formerly known as vulvovaginal atrophy: The Genitourinary Syndrome of Menopause: An Overview of the Recent Data [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Cureus. 2020 Apr 8;12(4):e7586. doi: 10.7759/cureus.7586. There are 167 similar articles in PubMed Central. The article has been cited by ten articles.

4-2. Sexual dysfunction

Key points: Sexual dysfunction

• 1. Increase in age and decreased serum estrogen levels lead to harmful effects on sexual function and cause dyspareunia and reduction of sexual desire and sexual response.
• 2. Measuring the serum level of a sex hormone does not provide much help in diagnosing and treating sexual dysfunction, and conducting a blood test for testosterone to diagnose androgen deficiency in healthy women is not advised.
• 3. When considering sexual dysfunction, the role of vaginal atrophy should always be considered.
• 4. Systemic MHT and low-dose vaginal ET are effective for treating urogenital atrophy and improve sexual function by increasing vaginal lubrication, blood flow, and sensory function as well as improve dyspareunia in particular.
• 5. Regarding female MHT for women with HSDD*, percutaneous therapy is preferred over oral therapy and tibolone is effective for treating female sexual dysfunction by increasing women’s sexual desire and arousal.

*HSDD-“Hypoactive sexual desire disorder (HSDD) is defined as a persistent or recurrent deficiency (or absence) of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty not related to a medical or psychiatric condition or the use of a substance or medication.”1, 2: Evaluation and Management of Hypoactive Sexual Desire Disorder [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Sex Med. 2018 Jun;6(2):59-74. doi: 10.1016/j.esxm.2018.01.004. Epub 2018 Mar 6. There are 156 similar articles in PubMed Central. The article has been cited by eight articles.

5. Coronary artery disease

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