An updated guide for managing menopause

The Practitioner’s Toolkit for Managing Menopause has now been updated and is available to everyone, not just medical practitioners.

Menopause remains somewhat in the shadows of clinical practice, with many women needlessly experiencing symptoms that impair their quality of life (here). Up to 74% of Australian women aged less than 55 years experience vasomotor symptoms (VMS; hot flushes and night sweats) (here). Past data suggest VMS are moderate to severely bothersome for 28% of Australian women, and that very bothersome VMS are associated with moderate to severe depressive symptoms (here).

Yet an estimated 85% of Australian women with bothersome menopausal symptoms are not receiving appropriate care, despite the availability of effective and safe hormonal and non-hormonal therapies. Oestrogen deficiency also causes symptomatic vulvovaginal atrophy (VVA) in at least 50% of postmenopausal women, and VVA correlates strongly with sexual dysfunction.

But fewer than 5% of postmenopausal women aged less than 65 years use vaginal oestrogen therapy (here), which is inexpensive, effective and safe. Most importantly, menopause is not simply about symptoms. The hormonal changes contribute to central fat accumulation, a more adverse lipid profile and bone loss, increasing the risks of cardiometabolic disease and osteoporosis.

The difficulties of seeking care

Inadequate menopause-related health care is not simply a result of systemic barriers to health care delivery. Individual knowledge about menopause, as well as taboos and other cultural factors among culturally and linguistically diverse and Indigenous Australian women, may have an impact on women seeking care. However, a major barrier to quality menopause care is the lack of health care practitioner knowledge and confidence in managing menopause. This may be further compounded by health care professionals’ acknowledged lack of confidence in delivering culturally appropriate care (here).

Practitioner’s Toolkit

The first Practitioner’s Toolkit for Managing Menopause was developed in 2014 to address the gap in health care professionals’ knowledge about menopause. Designed for point-of-care use, the Toolkit provides pragmatic guidance and simple algorithms for the assessment, investigation and management of women at midlife.

The Toolkit has now been updated to ensure it aligns with current best practice. This was achieved by a systematic review of guidelines, position and consensus statements on menopause published after the development of the original 2014 Toolkit, and additional searches of peer-reviewed literature were conducted to address any information gaps.

The Toolkit was then reviewed by international menopause experts and has been endorsed by the International, Australasian and British Menopause Societies, the Endocrine Society of Australia, and Jean Hailes for Women’s Health. It is designed for worldwide use and can be easily adapted to a local context. As part of the National Health and Medical Research Council-funded MenoPROMPT program, the Toolkit will be incorporated into general practice software, facilitating point-of-care individualised menopause assessment and management.

Key updates

Key updates to the Toolkit include clarification about evidence-based indications for menopausal hormone therapy (MHT). Although MHT is indicated for VMS, menopause-associated sleep disturbance or mood change, and vaginal symptoms, the evidence does not support its use for clinical depression or impaired memory and concentration as sole symptoms; these conditions should be assessed and managed in their own right.

New guidance is provided about the bone health implications of menopause. Bone health was not specifically addressed in the 2014 Toolkit, but the literature review identified this as a key area where further guidance for practitioners is needed.

During the menopause transition, bone loss accelerates in all women, regardless of whether they have VMS. Furthermore, most postmenopausal women who have fragility fractures have either osteopenia (T-score between −2.5 and −1.0) or normal bone mineral density (T-score > −1.0). Although osteoporosis guidelines support MHT for the prevention of fragility fractures and osteoporosis, clear guidance for when MHT can be used in asymptomatic women with osteopenia is lacking.

The Toolkit provides a simple algorithm for bone health assessment and management of postmenopausal women aged under 65 years without a minimal trauma fracture, and recommends consideration of MHT for prevention of bone loss and fracture in women with a T-score of –1.8 or below but greater than –2.5.

Other changes include updating of drug doses and greater clarification for when non-oral oestrogen preparations should be considered. Guidance is provided about novel therapies that may be available in Australia in the future, including fezolinetant (a non-hormonal neurokinin 3B receptor antagonist), low-dose oxybutynin for VMS, and ospemifene and vaginal dehydroepiandrosterone (DHEA) for urogenital symptoms.

Although not considered a standard component of MHT, the Toolkit reaffirms the use of transdermal testosterone preparations specially formulated for women (approved by the Therapeutic Goods Administration) for postmenopausal women experiencing a loss of sexual desire causing personal concern or distress.

The updated Toolkit is recommended to all clinicians who are either involved in women’s health, or care for women at midlife. Awareness of menopausal symptoms and management options are essential so that women receive the right care at menopause, and to prevent longer term health consequences.

The Toolkit will also help ensure women receive more streamlined and personal care by enabling clinicians to feel more confident to discuss all the possible hormonal and non-hormonal management options specific to individual women’s circumstances. Women will benefit by being able to make informed choices about what suits their needs best in a shared model of care.

Who can access the Toolkit?

While the Toolkit is primarily aimed at health care practitioners, it is freely available to anyone who would like to know more about menopause. Raising awareness of the Toolkit among women generally will empower women to seek evidence-based care from their health care providers and participate in shared decision making.

Going forward, a number of key issues still need to be managed to improve the health of women at menopause. As has been highlighted elsewhere, more government investment in women’s health at midlife is needed, including specific Medicare funding for menopause-related care (eg, midlife health checks for women) and an expanded eligibility criteria for Medicare Benefits Schedule-funded dual-energy x-ray absorptiometry scans. Education of health care professionals throughout their training, starting in medical school, is essential. Raising public awareness of the silent health impacts of menopause is also urgently needed.

Further research is needed in a number of key areas, such as the safety of MHT regimens including progesterone, the management of perimenopause, and the impact of menopause on women’s paid and unpaid roles, such as carer and volunteer work, in the community.

Finally, it is important to recognise that successfully treating and supporting women as they experience menopause depends on more than just the skill of individual health care professionals, it requires the involvement and support of broader societal structures, including the government, the health system, and the community in general. Although the Toolkit is a significant step in improving the care of women at midlife, more still needs to be done.

You can access the toolkit online.

Dr Sasha Taylor is a Research Fellow at the Women’s Health Research Program at the School of Public Health and Preventive Medicine at Monash University in Melbourne.

Dr Chandima Hemachandra is a Research Fellow at the Women’s Health Research Program at the School of Public Health and Preventive Medicine at Monash University in Melbourne.

Professor Susan Davis is a National Health and Medical Research Council Investigator and the Director of the Women’s Health Research Program at the School of Public Health and Preventive Medicine at Monash University in Melbourne.

Competing interests: Professor Susan R Davis reports honoraria from Besins Healthcare, Mayne Pharma, Health Ed, BioSyent, Lawley Pharmaceuticals, Abbott Laboratories and Que Oncology. She has served on Advisory Boards for Mayne Pharma, Astellas Pharmaceuticals, Theramex, and Gedeon Richter and has been an institutional investigator for Que Oncology and Ovoca Bio.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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