The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society

Updates in nonhormonal therapy for perimenopausal and menopausal symptoms

PURPOSE OF REVIEW

Perimenopausal and menopausal symptoms are common and may significantly impact quality of life. Menopausal hormone therapy is the most effective treatment but may not be appropriate in all cases. Nonhormonal alternatives range from lifestyle changes and dietary supplements to medical interventions and prescription therapies. This review will summarize the newest advancements in nonhormonal therapies for bothersome perimenopausal and menopausal symptoms.

RECENT FINDINGS

The Menopause Society recently updated their recommendations and guidelines for nonhormonal therapies. Previous recommendations, such as clonidine and pregabalin, are no longer recommended. A new class of medication, neurokinin B antagonists, are now available to target vasomotor symptoms and show promise in addressing sleep and mood issues.

SUMMARY

Well tolerated, effective nonhormonal therapies are available to address perimenopausal and menopausal symptoms for those patients who are not candidates for or chose not to use menopausal hormone therapy.

Exploring the clinical, psychological, and social relevance of menopause for trans and gender diverse people: a qualitative study

OBJECTIVE

The aim of this study was to explore the meanings and experiences of menopause for trans and gender diverse (TGD) people and how menopause affects clinical practice.

METHODS

For this qualitative study in 2021-2022, a scoping literature review informed interview schedule development. Following email invitations, online semi-structured interviews were conducted in March-April 2021 in Australia with three prominent TGD community leaders (trans male, trans female, nonbinary person) and three experienced medical practitioners (general practitioner, endocrinologist, psychiatrist), which were audio-recorded and transcribed. Inductive, iterative thematic analysis of transcripts was conducted. A further literature search was completed in 2024.

RESULTS

Themes identified included the following: (1) no consensus on the definition of menopause for TGD individuals; (2) diverse menopause experiences existing in the TGD community; (3) large variations present regarding perimenopausal hormone therapy for older TGD patients: maintain dose, taper to low dose, or cease hormones; and (4) minimal support for TGD people to discuss menopause and concerns around aging. Saturation was not reached with the sample size.

CONCLUSIONS

There is a paucity of relevant research and no consensus on definitions, management, or impacts of menopause for TGD people. Therefore, current management approaches should be individually tailored and guided by clinical expertise. To formulate practical and realistic recommendations for clinical practice, future research could include the following: (1) a broader literature review into varied gender-affirming hormone treatment (GAHT) regimens among aging TGD people; (2) utilizing the Delphi technique to achieve expert consensus regarding GAHT in older TGD individuals; and (3) a prospective study design of TGD participants on different GAHT regimens over time.

A mediating role of visceral adipose tissue on the association of health behaviours and metabolic inflammation in menopause: a population-based cross-sectional study

Fat distribution changes with advancing menopause, which predisposes to metabolic inflammation. However, it remains unclear, how health behaviours, including sleeping, eating and physical activity, or their combinations contribute to metabolic inflammation caused by visceral adipose tissue (VAT). The aim of the present study was to examine whether health behaviours are associated with metabolic inflammation and whether VAT mediates these associations in menopausal women. This cross-sectional study consisted of a sample of middle-aged women (n = 124). Health behaviours were assessed by self-report questionnaire with measures of sleeping, eating (Eating Disorder Examination Questionnaire, EDE-Q), and physical activity behaviours. Metabolic inflammation was measured using GlycA, a composite biomarker of inflammation, and bioimpedance device was used to assess VAT. Structural equation modelling was used to examine the direct and indirect associations of health behaviours with inflammation, as well as the moderation effect of health behaviours on VAT and metabolic inflammation. VAT was directly associated with inflammation. Two indirect pathways were found: eating and physical activity behaviours were both inversely associated with inflammation through VAT, whereas sleeping behaviour was not. Physical activity moderated the association between VAT and metabolic inflammation. The association was stronger in those who were physically less active. Furthermore, eating behaviour and physical activity had an interaction on VAT. Physical activity was negatively associated with VAT among women with normal eating behaviour, but the association was less clear among women with features of disordered eating behaviour. It is possible to impede the menopausal shift to adverse visceral adiposity through increased physical activity and further decrease the risk of metabolic inflammation in menopausal women. The present study offers potential hypotheses for future longitudinal research.

Preworkout dietary nitrate magnifies training-induced benefits to physical function in late postmenopausal women: a randomized pilot study

To inform end points for future work, we explored the utility of preworkout (i.e., an acute dose before training) beetroot juice (BRJ) combined with exercise (BRJ + EX) to augment indices of physical function in postmenopausal women compared with exercise only (EX). A two-arm pilot study was used to compare 24 postmenopausal women following an 8-wk, circuit-based exercise intervention. Participants were randomized to BRJ + EX (n = 12) or EX (n = 12). BRJ + EX participants consumed 140 mL of BRJ 120-180 min (only) before training for 7 wk, then discontinued during the final week to mitigate carryover effects. Physical function indices were 6-min walk test (6MWT), estimated V̇o2peak, heart rate recovery (HRR), and maximal knee extensor power (Pmax). A treadmill task was used to measure V̇o2 on-kinetics wherein mean response time (MRT) coincided with the duration to reach 63% of steady-state V̇o2. Results showed greater changes (Δ) among BRJ + EX participants for 6MWT distance (40 ± 23 m vs. 8 ± 25 m; P = 0.003, d = 1.35), ΔV̇o2peak (1.5 ± 0.9 mL·kg-1·min-1 vs. 0.3 ± 1.0 mL·kg-1·min-1; P = 0.008, d = 1.20), and ΔHRR (-10 ± 6 beats/min vs. -1 ± 9 beats/min; P = 0.017, d = 1.05). Large and medium effect sizes favoring BRJ + EX were detected for ΔPmax (P = 0.07, d = 0.83) and ΔMRT (P = 0.257, d = 0.50), respectively. In postmenopausal women, BRJ + EX appears to magnify some adaptive benefits to physical function including aerobic capacity and recovery beyond that of training without BRJ. Investigation into contributing mechanisms is needed.NEW & NOTEWORTHY Though exercise training represents the principal strategy to combat age-related decline, the attendant effects of menopause weaken aspects of exercise adaptation compared with premenopausal women and age-matched men. Here we provide important initial evidence that preworkout (i.e., an acute dose before training) beetroot juice coupled with an 8-wk, circuit-based exercise training intervention may uniquely benefit late postmenopausal women by enhancing indices of physical function including aerobic capacity and recovery.

Recurrent venous thromboembolism and vaginal estradiol in women with prior venous thromboembolism: A nested case-control study

OBJECTIVES

Whether vaginal estradiol use is associated with an increased risk of recurrent venous thromboembolism (VTE) in women with prior VTE is unknown. We sought to evaluate the association between vaginal estradiol use and recurrent VTE in women with prior VTE.

METHODS

We performed a nationwide nested case-control study among 44 024 women aged ≥45 years who developed a first VTE without a history of vaginal estrogen use prior to VTE diagnosis. Cases with recurrent VTE were matched 1:2 on birth year with controls using incidence density sampling. Exposure to vaginal estradiol tablets was categorized into current use (0-2 months before index), prior use (2-24 months before index) and past use (more than 24 months prior to index).

RESULTS

We identified 5066 cases and 10 127 age-matched controls. In fully adjusted analysis vaginal estrogen was not associated with recurrent VTE with a hazard ratio of 0.75, p = .07 for current use, 0.83, p = .13 for prior use, and 1.24, p = .06 for past use.

CONCLUSION

Use of vaginal estradiol tablets in women with prior VTE was not associated with an increased rate of recurrent VTE. Our study indicates that vaginal estradiol therapy is unlikely to increase risk of recurrent VTE in women with prior VTE.

Liuwei Dihuang pills attenuate ovariectomy-induced bone loss by alleviating bone marrow mesenchymal stem cell (BMSC) senescence via the Yes-associated protein (YAP)-autophagy axis

CONTEXT

Liuwei Dihuang pill (LWDH) has been used to treat postmenopausal osteoporosis (PMOP).

OBJECTIVE

To explore the effects and mechanisms of action of LWDH in PMOP.

MATERIALS AND METHODS

Forty-eight female Sprague-Dawley rats were divided into four groups: sham-operated (SHAM), ovariectomized (OVX), LWDH high dose (LWDH-H, 1.6 g/kg/d) and LWDH low dose (LWDH-L, 0.8 g/kg/d); the doses were administered after ovariectomy via gavage for eight weeks. After eight weeks, the bone microarchitecture was evaluated. The effect of LWDH on the differentiation of bone marrow mesenchymal stem cells (BMSCs) was assessed via osteogenesis- and lipogenesis-induced BMSC differentiation. The senescence-related biological indices were also detected using senescence staining, cell cycle analysis, quantitative real-time polymerase chain reaction and western blotting. Finally, the expression levels of autophagy-related proteins and Yes-associated protein (YAP) were evaluated.

RESULTS

LWDH-L and LWDH-H significantly modified OVX-induced bone loss. LWDH promoted osteogenesis and inhibited adipogenesis in OVX-BMSCs. Additionally, LWDH decreased the positive ratio of senescence OVX-BMSCs and improved cell viability, cell cycle, and the mRNA and protein levels of p53 and p21. LWDH upregulated the expression of autophagy-related proteins, LC3, Beclin1 and YAP, in OVX-BMSCs and downregulated the expression of p62.

DISCUSSION AND CONCLUSIONS

LWDH improves osteoporosis by delaying the BMSC senescence through the YAP-autophagy axis.

Hormone therapy and venous thromboembolism risk in women of menopausal age: a target trial emulation

Contemporary data from randomized clinical trials focusing on the effect of oral hormone therapy (HT) on venous thromboembolism (VTE) in women aged 50-60 years are scarce despite evolving HT regimens. Here, we evaluated the association between HT and the risk of developing VTE using a target trial emulation among women of menopausal age. This retrospective cohort study applied a target trial emulation framework using claims data from a universal health insurance program in Taiwan. We emulated a sequence of trials in which women aged 50-60 years with no previous history of HT, hysterectomy, gynecologic disorders, or cardiovascular events were enrolled. Eligibility and HT use were evaluated monthly from 2011 to 2019. Eligible women were classified as either HT initiators or non-initiators for each consecutive month. Observational analogs of the intention-to-treat and per-protocol effects were estimated using pooled logistic regression models. Of the 150,686,148 eligible person-trials (3,001,112 women), 192,215 initiators and 768,860 propensity score-matched non-initiators were included in the analysis. The average duration of the HT was 1.25 years. Over a median follow-up of 5.83 years, 3,334 women developed VTE. The estimated hazard ratio (95% confidence interval) was 0.96 (0.88, 1.04) in the intention-to-treat analysis and 0.66 (0.41, 1.05) in per-protocol analysis. The estimated intention-to-treat and per-protocol 5-year VTE-free survival differences (95% confidence interval) were 0.1‰ (- 0.3‰, 0.7‰) and 0.3‰ (- 2.8‰, 4.0‰), respectively. In the contemporary clinical setting, we did not observe an increased VTE risk associated with HT in women aged 50-60 years.

Combined effects of high-intensity focused electromagnetic therapy and pelvic floor exercises on pelvic floor muscles and sexual function in postmenopausal women

OBJECTIVE

This study aimed to explore the impact of high-intensity focused electromagnetic therapy (HIFEMT) on the pelvic floor muscles (PFM), sexual function, and quality of life (QoL) among postmenopausal women.

METHODS

Fifty postmenopausal women with PFM weakness and sexual dysfunction were randomly allocated into two equal groups. The HIFEMT group participated in the PFM training program in addition to HIFEMT, whereas the control group performed PFM training only. For 12 weeks, HIFEMT was scheduled twice a week, while PFM training was performed daily. At baseline and after 12 weeks, PFM strength and endurance were assessed using a perineometer, sexual function was examined using the female sexual function index (FSFI), and QoL was assessed through the menopause-specific quality of life questionnaire (MENQOL).

RESULTS

The HIFEMT and control groups showed significant increases in PFM strength and endurance and FSFI scores, and significant declines in MENQOL compared with baseline measures (P<0.05). Compared to the control group, the HIFEMT group showed substantial improvements in all measured variables after 12 weeks (P<0.05).

CONCLUSION

Addition of HIFEMT to PFM training improved the PFM strength, endurance, sexual function, and QoL in postmenopausal women with PFM weakness and sexual dysfunction.

A systematic approach to the management of menses prophylaxis and suppression in pre-menopausal hematologic cancer patients

OBJECTIVE

Hematologic malignancies in women of reproductive age carry significant additional morbidity due to menstrual bleeding in conjunction with disease and treatment-associated cytopenias. Several agents for menses prophylaxis and suppression exist, but there is a paucity of data comparing these therapies, particularly in the cancer setting.

DATA SOURCES

A thorough literature review and evaluation of available data was conducted via PubMed search and combined with clinical expertise.

DATA SUMMARY

The goal of prophylaxis therapy is to induce amenorrhea until it is considered safe to resume menstrual cycles. GnRH agonists remain the management of choice in achieving menses control and amenorrhea. Suppression is more likely achieved when the therapy is initiated in the late luteal phase or with the concomitant use of oral contraceptives. The effective use of oral contraceptives is achievable in appropriately selected patients. Although attractive as prophylactic agents, GnRH agonists have a slow onset of amenorrhea and can be associated with an initial increase in bleeding, thus are of limited value in immediate menorrhagia management. We recommend prioritizing estrogen therapy given its documented efficacy, and adding tranexamic acid as a secondary agent for severe or refractory bleeding.

CONCLUSIONS

Thus far in the literature, this is the most comprehensive proposed pathway for the prevention and suppression of menorrhagia in hematologic cancer patients. Our protocol provides a step-wise approach for the management of menses prophylaxis and suppression to provide standardization amongst clinicians and adaptations for patient-specific needs.

Hypogonadism and nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD), recently proposed to be renamed to metabolic dysfunction-associated steatotic liver disease (MASLD), is a major global public health concern, affecting approximately 25-30% of the adult population and possibly leading to cirrhosis, hepatocellular carcinoma, and liver transplantation. The liver is involved in the actions of sex steroids via their hepatic metabolism and production of the sex hormone-binding globulin (SHBG). Liver disease, including NAFLD, is associated with reproductive dysfunction in men and women, and the prevalence of NAFLD in patients with hypogonadism is considerable. A wide spectrum of possible pathophysiological mechanisms linking NAFLD and male/female hypogonadism has been investigated. As therapies targeting NAFLD may impact hypogonadism in men and women, and vice versa, treatments of the latter may affect NAFLD, and an insight into their pathophysiological pathways is imperative. This paper aims to elucidate the complex association between NAFLD and hypogonadism in men and women and discuss the therapeutic options and their impact on both conditions.

The comprehensive care of the post-SCAD patient

Spontaneous coronary artery dissection (SCAD) is the nonatherosclerotic, nontraumatic dissection of an epicardial coronary artery which is predominantly caused by intramural hematoma formation or intimal disruption. SCAD is an increasingly recognized cause of acute coronary syndrome (ACS) in young women and its true prevalence may be underestimated due to its underdiagnosis. The pathogenesis of SCAD is multifaceted and influenced by gender-specific factors, hormonal fluctuations, genetics, arteriopathies, and physical and emotional stressors. Although the pathogenesis of SCAD is multifaceted, current guidance on the care of the post-SCAD patient is limited. Moreover, it is necessary to address each of the different components contributing to the pathogenesis of SCAD in order to improve outcomes and quality of life in this patient population. This literature review aims to consolidate the current knowledge on the medical management, rehabilitation, reproductive and mental health care, and comorbidities that affect SCAD survivors.

Familial catamenial coronary spasms

Coronary artery spasms represent important causes of myocardial ischaemia and infarction in patients with non-obstructive coronary artery disease. They are notably seen in younger people and occur almost equally in men and women. Besides traditional risk factors (ie, smoking), female hormones might also play a role.We report of two young sisters who presented with myocardial infarction caused by catamenial coronary spasms (CS), that is, during menstruation. In one of these women, this resulted in heart failure with a severely reduced ejection fraction and ultimately a heart transplant because of intractable ventricular arrhythmias.CS might result from changing hormone levels (especially oestrogen) during menstruation. Increased awareness of the occurrence of catamenial CS is essential for diagnosis and consequent treatment with coronary vasodilators and/or specific oestrogen/progesterone regimens.

Efficacy and safety of fezolinetant for vasomotor symptoms in postmenopausal women: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Vasomotor symptoms (VMS), such as hot flashes and night sweats, are highly prevalent and burdensome for women experiencing menopausal transition. Fezolinetant, a selective neurokinin 3 receptor (NK3R) antagonist, is a potential therapeutic option for mitigating VMS.

OBJECTIVES

Our aim is to assess the efficacy and evaluate the safety profile of fezolinetant compared with placebo in post-menopausal women suffering from VMS, by pooling all the relevant data and reflecting the most current evidence.

SEARCH STRATEGY/SELECTION CRITERIA

An extensive literature search was performed in the PubMed, Medline and Cochrane Library databases from inception until June 2023 to identify relevant trials.

DATA COLLECTION AND ANALYSIS

Mean differences (MDs) and 95% confidence intervals (CIs) were calculated for continuous outcomes. Risk ratios (RRs) were calculated for dichotomous outcomes. All statistical analyses were performed using R Statistical Software.

MAIN RESULTS

A total of six randomized controlled trials were added. For the frequency of daily VMS, the combined pooled result favored the fezolinetant group over placebo (MD -2.38, 95% CI -2.64 to -2.12; P < 0.001, I2 = 0%). For the severity of daily VMS, fezolinetant was again found to be superior to the placebo group (MD -0.40, 95% CI -0.51 to -0.29; P < 0.001, I2 = 70%). Fezolinetant (120 mg) consistently demonstrated a significant reduction in the severity of daily moderate/severe VMS compared with other doses at both 4 and 12 weeks. Patient-reported outcomes (PROs) of Greene Climacteric Scale (GCS), PROMIS the Sleep Disturbance Short Form 8b and Menopause-Specific Quality of Life (MENQoL) scores indicated significant improvement with fezolinetant. No significant difference in efficacy of fezolinetant at 4 and 12 weeks were observed in any outcome. As for safety, no significant differences in the treatment emergent adverse events at 12 weeks were found between fezolinetant and placebo.

CONCLUSIONS

Our study significantly favors fezolinetant over placebo regarding the primary efficacy outcomes of daily moderate to severe VMS frequency and severity, including PROs, while both the groups are comparable in terms of treatment emergent adverse events. Further studies are needed to confirm these findings.

Effect of menopausal hormonal therapy on cardiovascular risks in Korean postmenopausal women: A nationwide cohort study

OBJECTIVE

To evaluate the association between menopausal hormonal therapy (MHT) and the risk of cardiovascular disease (CVD), according to various regimens, dosages, routes of administration and starting ages of MHT.

DESIGN

A population-based cohort study using the Korean National Health Insurance Services database.

SETTING

Nationwide health insurance database.

POPULATION

Women who reported entering menopause at an age of ≥40 years with no history of CVD in the national health examination.

METHODS

The study population comprised 1 120 705 subjects enrolled between 2002 and 2019, categorised according to MHT status (MHT group, n = 319 007; non-MHT group, n = 801 698).

MAIN OUTCOME MEASURES

Incidence of CVD (a composite of myocardial infarction and stroke).

RESULTS

The incidence of CVD was 59 266 (7.4%) in the non-MHT group and 17 674 (5.5%) in the MHT group. After adjusting for confounding factors, an increased risk of CVD was observed with the administration of tibolone (hazard ratio, HR 1.143, 95% CI 1.117-1.170), oral estrogen (HR 1.246, 95% CI 1.198-1.295) or transdermal estrogen (HR 1.289, 95% CI 1.066-1.558), compared with the non-MHT group; the risk was based on an increased risk of stroke. The risk trends were consistent regardless of the age of starting MHT or the physicians' specialty. Among tibolone users, a longer period from entering menopause to taking tibolone and the use of any dosage (1.25 or 2.5 mg) were linked with a higher risk of CVD, compared with non-MHT users.

CONCLUSIONS

This nationwide cohort study demonstrated an increased risk of CVD, driven mainly by an increased risk of stroke, among tibolone and oral or transdermal estrogen users, compared with that of non-MHT users.

Effects of tibolone combined with zoledronic acid on bone density, bone metabolism, and pain in postmenopausal patients with osteoporosis

OBJECTIVE

To explore the efficacy and safety of tibolone combined with zoledronic acid in the treatment of postmenopausal osteoporosis (PMO).

METHODS

We conducted a retrospective analysis of 121 PMO patients from March 2019 to July 2021. Patients were divided into two groups based on treatment regimen: an observation group (n=62) receiving zoledronic acid combined with tibolone and a control group (n=59) receiving tibolone monotherapy. We evaluated and compared therapeutic efficacy, bone mineral density, bone metabolism markers (osteocalcin, serum C-terminal telopeptide of type I collagen, and bone alkaline phosphatase), pain, knee joint function, incidence of fragility fractures, and adverse reactions. Logistic regression analysis was used to evaluate risk factors affecting treatment efficacy.

RESULTS

The observation group showed a significantly higher therapeutic effect (96.77%) compared to the control group (83.05%), and a lower incidence of fragility fractures (P=0.012). Before treatment, there were no significant differences in bone mineral density, bone metabolism markers, pain status, or knee function between the two groups (all P>0.05). However, after treatment, evaluations showed marked improvements in these parameters in both groups, with more significant enhancements observed in the observation group (all P<0.001). The incidence of adverse reactions did not significantly differ between the groups (20.97% vs 13.56%, P=0.282). Logistic regression analysis identified the use of tibolone combined with zoledronic acid as a protective factor for effective treatment.

CONCLUSIONS

Tibolone combined with zoledronic acid significantly increases bone mineral density, improves bone metabolism, and reduces pain in PMO patients, with a safety profile comparable to that of monotherapy. This regimen should be considered for clinical use in treating PMO.

Effect of continuous nursing on treatment compliance and side effect management of coronary heart disease

BACKGROUND

There are relatively few studies on continuing care of coronary heart disease (CHD), and its research value needs to be further clarified.

AIM

To investigate the effect of continuous nursing on treatment compliance and side effect management in patients with CHD.

METHODS

This is a retrospective study with patients from January 2021 to 2023. The study was divided into two groups with 30 participants in each group. Self-rating anxiety scale (SAS) and Self-rating depression scale (SDS) were used to assess patients' anxiety and depression, and medical coping questionnaire was used to assess patients' coping styles. The pelvic floor dysfunction questionnaire (PFDI-20) was used to assess the status of pelvic floor function, including bladder symptoms, intestinal symptoms, and pelvic symptoms.

RESULTS

SAS score decreased from 57.33 ± 3.01before treatment to 41.33 ± 3.42 after treatment, SDS score decreased from 50.40 ± 1.45 to 39.47 ± 1.57. The decrease of these two indexes was statistically significant (P < 0.05). PFDI-20 scores decreased from the mean 16.83 ± 1.72 before treatment to 10.47 ± 1.3the mean after treatment, which was statistically significant (P < 0.05).

CONCLUSION

The results of this study indicate that pioneering research in continuous care of CHD has a positive impact on improving patients' treatment compliance, reducing anxiety and depression levels, and improving coping styles and pelvic floor functional status.

In the land of not-unhappiness: On the state-of-the-art of targeting aging and age-related diseases by biomedical research

The concept of the Land of Not-Unhappiness refers to the potential achievement of eliminating the pathologies of the aging process. To inform of how close we are to settling in the land, we summarize and review the achievements of research on anti-aging interventions over the last hundred years with a specific focus on strategies that slow down metabolism, compensate for aging-related losses, and target a broad range of age-related diseases. We critically evaluate the existing interventions labeled as "anti-aging," such as calorie restriction, exercise, stem cell administration, and senolytics, to provide a down-to-earth evaluation of their current applicability in counteracting aging. Throughout the text, we have maintained a light tone to make it accessible to non-experts in biogerontology, and provide a broad overview for those considering conducting studies, research, or seeking to understand the scientific basis of anti-aging medicine.

Fezolinetant for the treatment of vasomotor symptoms associated with menopause: a meta-analysis

This systematic review and meta-analysis investigated the efficacy and safety of fezolinetant for the treatment of moderate-to-severe vasomotor symptoms (VMS) associated with menopause. PubMed, Cochrane Library, Embase and Web of Science were searched for randomized controlled trials (RCTs) published from inception to June 2023, comparing fezolinetant to placebo in postmenopausal women suffering from moderate-to-severe VMS. The mean difference and risk ratio were calculated for continuous and binary outcomes, respectively. R software was used for the statistical analysis, and RoB-2 (Cochrane) to assess the risk of bias. We performed subgroup analysis based on different dosing regimens. Five RCTs comprising 3302 patients were included. Compared with placebo, at 12-week follow-up, fezolinetant significantly reduced the daily frequency of moderate-to-severe VMS (weighted mean difference [WMD] - 2.36; 95% confidence interval [CI] - 2.92, -1.81) and daily severity of moderate-to-severe VMS (WMD -0.22; 95% CI -0.31, -0.13). Also, fezolinetant significantly improved the quality of life (WMD -0.42; 95% CI -0.58, -0.26) and sleep disturbance (WMD -1.10; 95% CI -1.96, -0.24). There were no significant differences between groups in adverse events. These findings support the efficacy and safety of fezolinetant for the treatment of VMS related to menopause.

Effect of hormone therapy on blood pressure and hypertension in postmenopausal women: a systematic review and meta-analysis

IMPORTANCE

Menopausal hormone therapy (HT) includes a wide variety of hormonal compounds, and its effect on blood pressure is still uncertain.

OBJECTIVE

The aim of this study was to assess evidence regarding the effect of HT on blood pressure in postmenopausal women and its association with arterial hypertension.

EVIDENCE REVIEW

This systematic review and meta-analysis included randomized clinical trials and prospective observational studies. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and the incidence of hypertension were assessed. All stages were independently performed by two reviewers. For blood pressure outcome, standardized mean differences (SMD) and 95% confidence intervals (95% CI) were calculated as effect measures. Heterogeneity was assessed using the I2 statistic. The results are presented based on the HT type. The incidence of hypertension was compared using descriptive analyses.

FINDINGS

Eleven studies were included with 81,041 women evaluated, of which 29,812 used HT. The meta-analysis, conducted with 8 studies and 1,718 women, showed an increase in SBP with the use of oral conjugated equine estrogens plus progestogen (SMD = 0.60 mm Hg, 95% CI = 0.19 to 1.01). However, oral or transdermal use of estradiol plus progestogen (SMD = -2.00 mm Hg, 95% CI = -7.26 to 3.27), estradiol alone, and tibolone did not show any significant effect. No significant effect on DBP was observed for any formulation. Women who used oral estrogen plus progestogen had a higher risk of incident hypertension than those who never used it.

CONCLUSIONS AND RELEVANCE

The effect of HT on blood pressure is influenced by the formulation used, especially the type of estrogen. The combined formulations of conjugated equine estrogens plus progestogen increased SBP and the risk of hypertension, which was not observed among estradiol plus progestogen, estradiol alone, and tibolone users.

Psychometric Evaluation of the MENQOL Instrument in Women Experiencing Vasomotor Symptoms Associated with Menopause

INTRODUCTION

Vasomotor symptoms (VMS) associated with menopause can negatively affect health-related quality of life (HRQoL). The Menopause-Specific Quality of Life (MENQOL) questionnaire has been developed to assess QOL specific to menopause. The objective of the current study was to assess the psychometric properties, sensitivity to change, and clinically meaningful within-patient change of the MENQOL using data from the fezolinetant SKYLIGHT 1 and 2 studies in individuals with VMS.

METHODS

Individuals aged ≥ 40 to ≤ 65 years with moderate-to-severe VMS (≥ seven hot flashes/day) were enrolled. In addition to MENQOL, eight patient-reported outcome (PRO) measures were used for the psychometric evaluation. All PRO assessments were completed at weeks 4 and 12 during the treatment period, and most were completed at baseline. Psychometric analyses included factor analysis and reliability, construct validity, and sensitivity to change assessments. The within-patient threshold for a clinically meaningful change in MENQOL was derived.

RESULTS

In total, 1022 individuals were included from SKYLIGHT 1 and 2. Mean MENQOL total score at baseline was 4.30, improving to 3.16 at week 12. The confirmatory factor analysis supported established MENQOL domain structure, including the overall score. The internal consistency of the MENQOL overall and domain scores was supported using Cronbach's alpha and McDonald's omega, and MENQOL construct validity was supported for overall and domain scores. Item-to-item and item-total correlations were generally sufficient, and moderate test-retest reliability was noted. The scales against which construct validity and responsiveness for MENQOL domains were examined were moderately related to the MENQOL domains in general, providing additional support for acceptable measurement properties of MENQOL in this population. A reduction in MENQOL overall score of ≥ 0.9 points was identified as responding to treatment (a clinically important threshold). Thresholds of 2.0 points for the vasomotor domain and 0.9 for the psychosocial domain were estimated, in addition to distribution-based threshold estimates of 0.8 and 1.2 for the physical and sexual domains, respectively.

CONCLUSIONS

The psychometric properties of the MENQOL overall and domain scores support use of this instrument to capture experiences among individuals with moderate-to-severe VMS associated with menopause and assess related endpoints in clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers NCT04003155 and NCT04003142.

Combined supplementation with hesperidin, phytosterols and curcumin decreases adiposity and improves metabolic health in ovariectomized rats

In recent years many women have looked for alternative therapies to address menopause. Hesperidin, phytosterols and curcumin are bioactive compounds that can ameliorate some cardiovascular risk factors associated with menopause, although there are no data concerning the effects of their combined supplementation. We used ovariectomized (OVX) rats, a postmenopausal model with oestrogen deficiency, to evaluate whether supplementation with a multi-ingredient (MI) including hesperidin, phytosterols and curcumin for 57 days would display beneficial effects against fat mass accretion and metabolic disturbances associated with menopause. Twenty OVX rats were orally supplemented with either MI (OVX-MI) or vehicle (OVX). Furthermore, 10 OVX rats orally received the vehicle along with subcutaneous injections of 17β-oestradiol biweekly (OVX-E2), whereas 10 rats were sham operated and received oral and injected vehicles (control group; SH). MI supplementation partly counteracted the fat mass accretion observed in OVX animals, which was evidenced by decreased total fat mass, adiposity index, the weight of retroperitoneal, inguinal and mesenteric white adipose tissue (MWAT) depots and MWAT adipocyte hypertrophy. These effects were accompanied by a significant decrease in the circulating levels of leptin and the mRNA levels of the fatty acid uptake-related genes Lpl and Cd36 in MWAT. These results were very similar to those observed in OVX-E2 animals. OVX-MI rats also displayed a higher lean body mass, lean/fat mass ratio, adiponectin-to-leptin ratio and insulin sensitivity than their OVX counterparts. Our findings can pave the way for using this MI formulation as an alternative therapy to manage obesity and to improve the cardiometabolic health of menopausal women.

Comparison of the effect of noninvasive radiofrequency with vaginal estrogen and vaginal moisturizer in the treatment of vulvovaginal atrophy in postmenopausal women: a randomized clinical trial

OBJECTIVE

To compare the effect of noninvasive radiofrequency (RF) with vaginal estrogen (E), and vaginal moisturizer (M) on improving vulvovaginal atrophy (VVA) in women with genitourinary syndrome of menopause.

METHODS

A total of 32 postmenopausal women who met the inclusion criteria were randomized into three intervention arms to receive one of the following treatments: three sessions of noninvasive RF therapy (RF arm); intravaginal estriol cream 1 mg applied daily for 2 weeks, followed by 1 mg applied two times weekly or 1 mg of estradiol vaginal fast-dissolving film applied daily for 2 weeks, followed by 1 mg applied two times weekly (E arm); and intravaginal moisturizer two times a week (M arm). Assessments at baseline and after 4 months were conducted using Vaginal Health Index score, Vaginal Maturation, visual analog scale for VVA symptoms (dyspareunia, dryness, and burning), and Menopause Rating Scale (MRS) for urogenital symptoms. Vaginal wall biopsies were administered to participants who consented, pretreatment and posttreatment (at baseline and after 4 months of follow-up).

RESULTS

After 4 months, the Vaginal Health Index showed an increase of 6.6 points in mean total score in the RF arm, also in the E arm (+7.3 points), with no significant improvement in the M arm (+1.5 points) (interaction effect: RF, E ≠ M, P < 0.001). Regarding vaginal maturation, there was a significant increase in superficial cells in the E arm (+31.3), with no significant changes in the RF (+9.3) and M (-0.5) arms (interaction effect: E ≠ M, P < 0.001). Vaginal pH decreased significantly in the E arm (-1.25), with a similar response in the RF arm (-1.7), with no significant improvement in the M arm (-0.25) (interaction effect: RF, E ≠ M, P < 0.001).There was a significant improvement in the MRS score for VVA symptoms in the three intervention arms, with no predominance of any arm, whereas the improvement in the total MRS score for urogenital symptoms showed a predominance of the RF arm (ΔRF: -7.8; ΔE: -3.5; ΔM: -2.3; RF ≠ E, M). According to histopathologic analysis, there was no statistically significant increase in glycogenation ( P = 0.691) or epithelial cone height ( P = 0.935), despite an increase in the median delta (difference between pretreatment and posttreatment) in the three intervention arms (glycogenation: RF arm Δ = +118.4%; E arm Δ = +130.9%; M arm Δ = +24.9%; epithelial cone height: RF arm Δ = +33.5%; E arm Δ = +18.6%; M arm Δ = +22.3%).

CONCLUSION

The effect of noninvasive RF on the treatment of vulvovaginal symptoms of genitourinary syndrome of menopause was similar to vaginal estrogen, except for hormonal cytology, and superior to vaginal moisturizer, with improvement in some histomorphometric parameters. These findings are promising, especially for the population that cannot or prefers not to use vaginal estrogen therapy.

Changes in menopausal symptoms comparing oral estradiol versus transdermal estradiol

OBJECTIVE

This study aimed to compare the efficacy and safety of oral and transdermal estradiol in alleviating menopausal symptoms.

METHOD

A total of 257 recently menopausal women were randomized into two groups. The t-E2 group received transdermal estradiol (2.5 g per day) (n = 128) and the o-E2V group received oral estradiol valerate (2 mg per day) (n = 129) for 24 weeks; both groups received micronized progesterone (200 mg per day). The primary outcome measure is the change in the modified Kupperman Menopausal Index (KMI) after 24 weeks of treatment. Menopausal symptoms were recorded at screening and at 4, 12 and 24 weeks using both the KMI and the Menopause Rating Scale (MRS).

RESULTS

Significant amelioration was observed by KMI and MRS scores for both groups after treatment (p < 0.001). The mean KMI scores showed no difference between the two groups. The mean MRS scores were similar between the two groups at baseline and after 4 weeks of treatment. The results showed statistical differences after 12 weeks and 24 weeks of treatment (p = 0.005 and p = 0.011). Both the after-treatment scores minus the baseline scores of KMI and MRS and the incidence of adverse effects showed no difference between the two groups.

CONCLUSIONS

This study shows that both transdermal and oral estradiol are effective in relieving menopausal symptoms, with little difference in treatment efficacy and safety.

CLINICAL TRIAL NUMBER

ChiCTR2300073146.

Summary of the 2023 Thai Menopause Society Clinical Practice Guideline on Menopausal Hormone Therapy

The Thai Menopause Society is an academic organization consisting of healthcare professionals engaged in menopause medicine. The position statement was first issued in 1994 and updated in 2003 and 2023. Herein, we reviewed the important updates of the 2023 position statement on menopausal hormone therapy (MHT) as an international reference for healthcare professionals in Thailand. An advisory panel of clinicians and research experts in the field of menopause reviewed the recommendation of published International Consensus Statements and updated the evidence using the MEDLINE database through PubMed. The evidence-based information and relevant publications were assessed, and a consensus on recommendations was subsequently achieved using the level of evidence to determine the recommendation strength and evidence quality. MHT remains the most effective treatment for vasomotor symptoms and genitourinary syndromes of menopause even after 20 years. Additionally, it is effective in preventing bone loss and fractures in postmenopausal women. The cardiovascular risk of MHT increased in women who initiated MHT after 60 years of age. Hormone therapy should be individualized following the hormone type, dose, administration route, use duration, and progestogen inclusion. The necessary pretreatment evaluation and appropriate follow-up recommendations were added for improved MHT standard care. The updated 2023 Clinical Practice Guideline on MHT is useful for gynecologists, general physicians, endocrinologists, and other healthcare professionals in treating menopausal women receiving hormone therapy in Thailand.

The menopausal transition period and cardiovascular risk

The menopausal transition period spans, on average, 2-8 years before the final menstrual period and is associated with an increase in clinical and subclinical cardiovascular risk. In this Review, we discuss the metabolic and cardiovascular changes that occur during the menopausal transition period and the role of ovarian ageing, chronological ageing and other ageing-related risk factors in mediating these changes. Disentangling the relative contributions of chronological and reproductive ageing to cardiovascular risk is challenging, but data from longitudinal studies in women transitioning from premenopause to post-menopause have provided valuable insights. We also discuss evidence on how cardiovascular risk is altered by premature or early menopause, surgical menopause, and vasomotor and other menopausal symptoms. Whether targeted interventions can slow the progression of atherosclerosis and subclinical disease during the menopausal transition, thus delaying or preventing the onset of cardiovascular events, remains to be determined. Furthermore, we consider the recommended strategies for cardiovascular risk reduction in women undergoing menopausal transition using the framework of the American Heart Association's Life's Essential 8 key measures for improving and maintaining cardiovascular health, and discuss the cardiovascular risks and benefits of menopausal hormone therapy. Finally, we also discuss novel therapies that might benefit this population in reducing cardiovascular risk.

Insufficient use of menopausal hormone therapy in Swedish women with early or premature menopause caused by bilateral oophorectomy: a register-based study

OBJECTIVE

To investigate the use of menopausal hormone therapy (MHT) in premenopausal women after bilateral oophorectomy.

DESIGN

Retrospective register-based cohort study.

SETTING

Sweden.

POPULATION

Swedish women aged 35-44 years without malignancy who underwent bilateral oophorectomy in 2005-2020 were identified using The Swedish National Quality Register of Gynaecological Surgery (GynOp).

METHODS

Data from GynOp were cross-linked with data on dispensed drugs extracted from the Swedish Prescribed Drug Register.

MAIN OUTCOME MEASURES

Proportion of women dispensed MHT at least once within 1 year after surgery. Repeated treatment episodes were defined, and the proportion of 'person time' covered by dispensations was analysed.

RESULTS

In total, 1231 of all women (n = 1706) were dispensed MHT at some point after surgery, with 1177 women dispensed MHT within 1 year. This proportion increased from 64% in 2005 to 84% in 2019 (p < 0.001). In the total population, 4537 'treatment years' transpired, corresponding to 43% of the mean time covered. In women dispensed MHT within 1 year, the proportion of time covered was 63%.

CONCLUSIONS

Only 69% of all women without malignancy of any kind who underwent bilateral oophorectomy were dispensed MHT within 1 year after surgery, and the duration of treatment was limited. It is important to study further the reasons behind the low dispensation rate in this group to increase adherence to current treatment guidelines, improve quality of life, and avoid increased morbidity and mortality.

Measurements of Postmenopausal Serum Estradiol Levels and Cardiovascular Events: A Systematic Review

Background

Cardiovascular disease (CVD) is the leading cause of death among female patients and its likelihood increases following menopause. However, whether estradiol levels are related to CVD remains unknown. We aimed to determine the association between serum estradiol levels and cardiovascular (CV) events in postmenopausal females.

Methods

Electronic databases (MEDLINE, Embase) were searched systematically from inception to October 2022. Studies were eligible for inclusion if they included the following: (i) postmenopausal females; (ii) examination of the association between total serum estradiol levels and CV events (CV mortality, CVD, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, heart failure, and CV hospitalization); (iii) original data (randomized controlled trial, quasi-experimental, cohort, case-control, or cross-sectional study). A narrative synthesis was completed because the data were not amenable to meta-analysis.

Results

Of the 9026 citations retrieved, 8 articles were included, representing a total of 5635 women. The risk-of-bias was fair, and considerable heterogeneity was present. In those not using menopausal hormone therapy, 3 studies demonstrated mixed results between estradiol levels and risk of coronary heart disease, and 1 study showed that higher estradiol levels were associated with an increased risk of myocardial infarction. No significant associations were present between estradiol levels and the remaining events (ie, CV mortality, heart failure, CVD, and stroke).

Conclusions

The association between serum estradiol levels and CV events in postmenopausal females remains unclear. Further studies assessing this association are warranted, given the elevated CVD risk in this population.

Resident training to optimize patient-focused menopause management: a multispecialty menopause curriculum to enhance knowledge and preparedness

OBJECTIVE

Surveys of residents in obstetrics and gynecology, internal medicine, and family medicine have demonstrated low levels of knowledge and comfort in treating patients with menopausal symptoms, suggesting a need for improved training during residency. To address this problem, we used a flipped classroom design to deliver a novel menopause curriculum for medical residents. The curriculum included six podcast episodes followed by an interactive case-based classroom session. We then assessed effects of the curriculum on the residents' knowledge and preparedness to manage menopause symptoms.

METHODS

We targeted 200 residents (43 obstetrics and gynecology, 86 internal medicine, and 71 family medicine) from six residency programs from 2019 to 2020. Of these, 115 (58%) completed both pre- and postcurriculum assessments, including a 15-item knowledge test and self-ratings of their knowledge, comfort, and preparedness to manage menopause.

RESULTS

Following the curriculum, the proportion of correctly answered knowledge questions rose from 60.8% to 79.1% (+18.3%; 95% confidence interval, 15.4-21.2; Cohen's d = 1.2). Improvement did not significantly differ by specialty or year of residency. There were higher gains for residents who listened to the entirety of all six podcast episodes ( b = 11.4, P < 0.001) and who attended the classroom session ( b = 11.6, P = 0.003). Residents' self-ratings of knowledge, comfort, and preparedness also improved following the curriculum across all medical specialties (Cohen's d = 0.47-1.2). Residents rated the podcast format as convenient (73%) and effective (65%) compared with an equivalent amount of reading.

CONCLUSIONS

Pairing a podcast with a classroom discussion was found to be an effective combination for improving menopause knowledge.

The benefits and risks of menopause hormone therapy for the cardiovascular system in postmenopausal women: a systematic review and meta-analysis

BACKGROUND

Menopause hormone therapy (MHT), as an effective method to alleviate the menopause-related symptoms of women, its benefits, risks, and potential influencing factors for the cardiovascular system of postmenopausal women are not very clear.

OBJECTIVES

To evaluate cardiovascular benefits and risks of MHT in postmenopausal women, and analyze the underlying factors that affect both.

SEARCH STRATEGY

The EMBASE, MEDLINE, and CENTRAL databases were searched from 1975 to July 2022.

SELECTION CRITERIA

Randomized Clinical Trials (RCTs) that met pre-specified inclusion criteria were included.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently. A meta-analysis of random effects was used to analyze data.

MAIN RESULTS

This systematic review identified 33 RCTs using MHT involving 44,639 postmenopausal women with a mean age of 60.3 (range 48 to 72 years). There was no significant difference between MHT and placebo (or no treatment) in all-cause death (RR = 0.96, 95%CI 0.85 to 1.09, I2 = 14%) and cardiovascular events (RR = 0.97, 95%CI 0.82 to 1.14, I2 = 38%) in the overall population of postmenopausal women. However, MHT would increase the risk of stroke (RR = 1.23, 95%CI 1.08 to 1.41,I2 = 0%) and venous thromboembolism (RR = 1.86, 95%CI 1.39 to 2.50, I2 = 24%). Compared with placebo, MHT could improve flow-mediated arterial dilation (FMD) (SMD = 1.46, 95%CI 0.86 to 2.07, I2 = 90%), but it did not improve nitroglycerin-mediated arterial dilation (NMD) (SMD = 0.27, 95%CI - 0.08 to 0.62, I2 = 76%). Compared with women started MHT more than 10 years after menopause, women started MHT within 10 years after menopause had lower frequency of all-cause death (P = 0.02) and cardiovascular events (P = 0.002), and more significant improvement in FMD (P = 0.0003). Compared to mono-estrogen therapy, the combination therapy of estrogen and progesterone would not alter the outcomes of endpoint event. (all-cause death P = 0.52, cardiovascular events P = 0.90, stroke P = 0.85, venous thromboembolism P = 0.33, FMD P = 0.46, NMD P = 0.27).

CONCLUSIONS

MHT improves flow-mediated arterial dilation (FMD) but fails to lower the risk of all-cause death and cardiovascular events, and increases the risk of stroke and venous thrombosis in postmenopausal women. Early acceptance of MHT not only reduces the risk of all-cause death and cardiovascular events but also further improves FMD, although the risk of stroke and venous thrombosis is not reduced. There is no difference in the outcome of cardiovascular system endpoints between mono-estrogen therapy and combination therapy of estrogen and progesterone.

Evaluating the cost utility of estradiol plus dydrogesterone for the treatment of menopausal women in China

AIM

Evaluate the cost utility of menopausal hormone therapy for women in China.

MATERIALS AND METHODS

A bespoke Markov cost utility model was developed to evaluate a cohort of symptomatic perimenopausal women (>45 years) with intact uterus in China in accordance with China's Pharmacoeconomic guideline. Short (5-year) and long (10-year) treatment durations were evaluated over a lifetime model time horizon with 12-month cycle duration. Societal and healthcare payer perspectives were evaluated in the context of a primary care provider/prescriber, outpatient setting with inpatient care for patients with chronic conditions. Disease risk and mortality parameters were derived from focused literature searches, and China Diagnosis-related Group cost data was included. Comprehensive scenario, univariate and probabilistic sensitivity analysis were undertaken along with independent validation. This is the first model to include MHT-related disease risks.

RESULTS

According to base case results, the total cost for MHT was 22,516$ (150,106¥) and total quality adjusted life years 12.32 versus total cost of no MHT 30,824$ (205,495¥) and total quality adjusted life years 11.16 resulting in a dominant incremental cost effectiveness ratio of -7,184$ (-47,898¥) per QALY. Results hold true over a range of univariate deterministic sensitivity and scenario analyses. Probabilistic analysis showed a 91% probability of being cost effective at a willingness to pay threshold of three times Gross Domestic Product per capita in China.

CONCLUSION

Contingent on the structure and assumptions of the model, combination of estradiol plus dydrogesterone MHT is potentially cost saving in symptomatic women over the age of 45 years in China.

Midlife Women's Menopausal Transition Symptom Experience and Access to Medical and Integrative Health Care: Informing the Development of MENOGAP

Background

Individuals with a uterus experience menopause, the cessation of menses, on average at age 51 years in the United States. While menopause is a natural occurrence for most, over 85% of women experience multiple interfering symptoms. Menopausal women face health disparities, including a lack of access to high-quality healthcare and greater disparities are experienced by women who are black, indigenous, and people of color. Some women are turning away from hormone therapy, and some seek integrative health interventions.

Objective

Some menopausal women who seek healthcare do not receive it as they lack access to medical and integrative healthcare providers. A potential solution to this problem is a medical group visit (MGV), during which a provider sees multiple patients at once. The aims of this study were to gather women's opinions about the menopause, provider access, and conventional and integrative health interventions for later use to develop a menopause MGV.

Methods

We conducted a Community Engagement Session and a Return of Results (RoR) with midlife women to learn about their menopause experiences, barriers and facilitators to accessing health providers, and their interest in and suggestions for designing a future integrative MGV (IMGV). Thematic qualitative research methods were used to summarize session results.

Results

Nine women participated in the Session and six attended the RoR. Participants were well-educated and diverse in race and ethnicity. Themes included: an interest in this topic; unfamiliar medical terms; relevant social factors; desired whole person care; interest in integrative health; barriers and facilitators to accessing healthcare. The group expressed interest in ongoing participation in the future process of adapting an IMGV, naming it MENOGAP.

Conclusion

These findings highlight the importance of stakeholder engagement before designing and implementing MENOGAP and the great need among midlife women for education about the menopausal transition, integrative self-care, and healthcare.

Menopausal symptoms and attitudes toward hormone replacement therapy among Israeli women

Menopause occurs around midlife and is an inevitable component of women's aging. The study aimed to investigate the associations between the lifetime prevalence of menopausal symptoms and health-related characteristics among Israeli postmenopausal women aged 55-75 years. Additionally, this study aimed to estimate the use of hormone replacement therapy (HRT) and women's attitudes toward this treatment. Data for this study were extracted from a cross-sectional national telephone survey conducted in Israel between 2018 and 2020. For the current study, only postmenopausal women aged 55-75 years were included. Multivariate analyses were used to identify demographic and health-related characteristics associated with menopausal symptoms. The study included 688 participants. Most (68.8%) reported one or more menopausal symptoms, specifically vasomotor symptoms (50.4%). According to the multivariate logistic regression analysis, menopausal symptoms were associated with moderate-high anxiety and/or depression symptoms (OR = 2.01, 95% CI 1.12-3.58) and with osteoporosis (OR = 1.78, 95% CI 1.08-2.92). Although most (78.3%) symptomatic women were bothered by their symptoms, 29.1% received any treatment for symptom relief and only 12.6% reported current or past use of HRT. The findings show that menopausal symptoms were associated with a higher prevalence of anxiety and/or depression symptoms and osteoporosis in the years following menopause. Most symptomatic women did not receive any treatment and the majority were against HRT. Knowledge and awareness about menopause and treatment options should be increased among Israeli women. Additionally, the promotion of positive attitudes toward menopause and HRT use among women and healthcare providers is strongly recommended.

Oestrogen-based therapies for menopausal symptoms

PURPOSE

To summarise the dosing options, regimens, pharmacokinetics, risks and benefits of oestrogen-based therapies for the treatment of menopausal symptoms.

METHODS

A review of the literature was undertaken using multiple databases. Randomised trials, observational studies, meta-analyses and review papers were included.

RESULTS

Multiple systemic preparations of oestrogen exist and all appear comparable in terms of efficacy. They differ by pharmacokinetics and those preparations that avoid hepatic metabolism have a lower risk profile in general although their use can be limited by skin barriers or patient acceptability. All vaginal oestrogen treatments are comparable in efficacy and have not been associated with any health risks. Side-effects between all preparations differ.

CONCLUSIONS

With regards to oestrogen treatments there is not a one size fits all. Multiple treatments are available and a clinician's role is to guide and help women make evidence based, unbiased and informed choices.

Fractional CO2 Laser, Radiofrequency and Topical Estrogen for Treating Genitourinary Syndrome of Menopause: A Pilot Study Evaluating the Vulvar Vestibule

Background and Objectives: Genitourinary syndrome of menopause (GSM) affects more than half of postmenopausal women. This study aimed to evaluate the clinical and histological aspects of microablative fractionated CO2 laser (CO2L), microablative fractionated radiofrequency (RF) and intravaginal estrogen (ET) therapy as GSM treatments for the vulvar vestibule. Materials and Methods: This study included postmenopausal women with at least one moderate-to-severe complaint of GSM. Women in the CO2L and RF groups received three monthly sessions of outpatient vulvovaginal therapy. The procedures were performed 30 min after applying 4% lidocaine gel to the vulva and vaginal introitus. Vulvar vestibular pain was assessed after each application using a 10-point VAS. A follow-up evaluation was performed 120 days after beginning each treatment. Digital images of the vulva were obtained and a 5-point Likert scale (1 = much worse, 2 = worse, 3 = neutral, 4 = better, 5 = much better) was used to assess the global post-treatment women's impression of improvement regarding GSM. Results: A significant change in clinical aspects of the vulva was observed after all treatments with a reduction in the atrophic global vulvar aspect and an enhancement of the trophic aspect. High satisfaction was also reported after treatment according to the Likert scale evaluation: CO2L (4.55 ± 0.97), RF (4.54 ± 0.95), CT (4 ± 1.41), p = 0.066. Histological evaluation revealed enhanced dermal papillae before pre-treatment, significantly reducing post-treatment in all groups (p = 0.002). No unintended effects were reported. Conclusions: CO2L, RF, and ET significantly improved GSM concerning the vulvar vestibule at the 4 months follow-up.

Advances in diagnosis and treatment of perimenopausal syndrome

With the development and progress of society, people's average life expectancy has increased, and relevant literature reports that the number of postmenopausal women in China continues to increase. With lifespans extended, the transition period and post-menopause period have become the longest essential period in every woman's life. The life quality of women troubled by perimenopausal syndrome has been significantly reduced, which also places a burden on families and society. It is well known that hormone replacement therapy plays a vital role in improving women's menopause-related symptoms and is the most effective medical measure. With research ongoing into the treatment of menopausal symptoms in different patients, dose size, treatment duration, and medication regimens for hormones are still hot topics of discussion. This article reviews the definition, clinical diagnosis, staging, clinical manifestations, and treatment of menopause and explores the current diagnosis and treatment scenarios of perimenopausal syndrome.

Tibolone and Breast Tissue: a Review

The safety profile of hormone replacement therapy (HRT) on breast is still controversial. Tibolone is an option of treatment for climacteric syndrome of postmenopausal women. Its risk profile on breast is debated. This is an updated narrative review focusing on the impact of tibolone on breast. Particularly, we will report data from major preclinical and clinical studies regarding the effects of the use of this compound on breast tissue and breast density. Moreover, we will analyze and discuss the most relevant findings of the principal studies evaluating the relationship between tibolone and breast cancer risk. Our purpose is making all clinicians who are particularly involved in women's health more aware of the effects of this compound on breast and, thus, more experienced in the management of menopausal symptoms with this drug. According to the available literature, tibolone seems to be characterized by an interesting safety profile on breast tissue.

Female aging: when translational models don't translate

For many pathologies associated with aging, female patients present with higher morbidity and more frequent adverse events from treatments compared to male patients. While preclinical models are the foundation of our mechanistic understanding of age-related diseases, the most common models fail to recapitulate archetypical female aging trajectories. For example, while over 70% of the top age-related diseases are influenced by the systemic effects of reproductive senescence, we found that preclinical studies that include menopausal phenotypes modeling those seen in humans make up <1% of published aging biology research. The long-term impacts of pregnancy, birthing and breastfeeding are also typically omitted from preclinical work. In this Perspective, we summarize limitations in the most commonly used aging models, and we provide recommendations for better incorporating menopause, pregnancy and other considerations of sex in vivo and in vitro. Lastly, we outline action items for aging biology researchers, journals, funding agencies and animal providers to address this gap.

Influence of the different hormonal status changes during their life on fat mass localisation in women: a narrative review

CONTEXT

Independently of the total body fat mass, upper body fat mass deposition is strongly associated with cardiometabolic comorbidities. The mechanisms underlying fat mass localisation are not fully understood, but evidences indicate sex-specific fat mass distribution. Currently, data on women are scarce and the link between hormonal status changes during their life and fat mass distribution is overlooked.

METHOD

For this narrative review, literature data were extracted from the PubMed and CENTRAL databases to examine the relationship between hormonal status and adipose tissue localisation in women.

RESULTS

Menopause strongly influences fat mass localisation, while the effect of the menstrual cycle phases, oral contraception use and pregnancy has not been unambiguously determined.

CONCLUSION

Reliable data are lacking on the relationship between hormonal variations throughout the lifespan and body fat mass localisation in women. Future studies should take into account the hormonal status of women to reduce the risk of cardiometabolic diseases.

Sleep During Menopause

Postmenopause is defined retrospectively after 12 consecutive months of amenorrhea. It represents the end of the reproductive period and ovarian failure. A decrease in estrogen leads to several changes in the short and long term. Among the early changes, vasomotor symptoms (hot flashes) are particularly common, occurring in about 70% of women. In addition, there are changes in mood, anxiety, depression, and insomnia. Insomnia occurs in almost 60% of postmenopausal women. Psychosocial aspects may also affect sleep. Proper diagnosis may lead to adequate treatment of sleep disturbances during menopause. Hormonal or other complementary therapies can improve sleep quality.

Management of menopause: a survey of physicians from the Middle East and Africa

OBJECTIVE

This study evaluated physicians' perceptions, practices, confidence, comfort level and prior training in managing menopause.

METHODS

A survey was conducted of a convenience sample of physicians from the Middle East and Africa (MEA) in 2019. We covered knowledge of symptoms, menopausal hormone therapy (MHT), other menopause management strategies and prior training in menopause medicine.

RESULTS

Of the 254 participants, 64.2% were seniors in family medicine (36.4%), endocrinology (36.0%), gynecology (15.8%) and internal medicine (13.8%). Fewer than one-third (28.8%) correctly identified the diagnostic criteria of menopause. Almost all recognized vasomotor symptoms (99.5%), vaginal dryness (96.2%) and mood disturbance (94.3%), but to a lesser extent other symptoms. Inconsistency and critical gaps were identified in responses to competence questions on six case studies. They recalled having occasional (43.2%) or no training (19.4%) in menopause medicine and rated their preparedness to treat menopause widely. A total of 66.2% agreed that training is very important. Variation between specialties was identified.

CONCLUSION

Many physicians recognize the importance of education in menopause management, but their responses revealed critical knowledge gaps that underscored the need for comprehensive, evidence-based menopause management.

Fibromyalgia and menopause: an open study on postmenopausal hormone therapy

BACKGROUND

Fibromyalgia women (FM) seems to get worse at menopause suggesting some influence of estrogens on its pathophysiology. We aimed to study the influence of postmenopausal hormone therapy (HT) in FM, the relationship with sleep and FM impact.

METHODS

We analyzed prospectively 69 menopausal women, divided in two groups, FM group (FMG; N.=32) and comparison group (CG; N.=28) submitted to HT for twelve weeks (1.2 mg/g transdermal estradiol, 100 mg micronized natural progesterone oral/daily). Data on Utian Quality of Life Questionnaire (UQOL) and Pittsburgh Sleep Quality Index (PSQI) were obtained in both groups, at entrance and twelve weeks after HT. FM patients also completed the Fibromyalgia Impact Questionnaire - Revised (FIQ-R) and fibromyalgia severity (FS).

RESULTS

FM patients improved significantly the FIQ-R (P=0.0001, median FIQ-R score 30% lower), mainly the severity of FM, assessed by FS (P<0.0001). Both groups had improved quality of life and sleep (UQOL: P=0.0001; P=0.001, PSQI: P<0.0001; P=0.007, respectively). Differences between first and second PSQI were greater for CG than for FMG (P=0.008).

CONCLUSIONS

HT improving sleep and quality of life in both groups; it was a significant clinical improvement seen by FIQ and FS in FM patients. These changes characterize improvement of functional status and symptoms severity.

Efficacy of Fractional Laser on Steroid Receptors in GSM Patients

BACKGROUND

To compare the efficacy of CO2 fractional laser with that of topical estriol for treating genitourinary syndrome of menopause and to investigate the relationship between epithelial thickness and vaginal atrophy.

METHODS

Twenty-five menopausal women were randomized to receive either laser or estrogen treatment. Vaginal biopsies before and after treatment were compared to assess the amount and distribution of estrogen and progesterone receptors.

RESULTS

Estrogen receptor levels were statistically similar between groups before and after treatment. Although there was no change over time in the estrogen group, an increase in receptor levels was confirmed in the laser group. Changes in estrogen receptor levels showed no association with treatment. Progesterone receptor levels were statistically similar between groups throughout treatment. There was no change over time in both groups. These changes displayed no association with the type of treatment. There was no significant correlation between epithelium thickness and estrogen or progesterone receptor levels.

CONCLUSIONS

Estrogen and progesterone receptor levels increased and were maintained, respectively, in the vaginal epithelium in both groups. There was no significant relationship between epithelium thickness and receptor density. Laser therapy had similar outcomes to the gold standard without involving the disadvantages of hormone therapy.

Transdermal drug delivery via microneedles for musculoskeletal systems

As the population is ageing and lifestyle is changing, the prevalence of musculoskeletal (MSK) disorders is gradually increasing with each passing year, posing a serious threat to the health and quality of the public, especially the elderly. However, currently prevalent treatments for MSK disorders, mainly administered orally and by injection, are not targeted to the specific lesion, resulting in low efficacy along with a series of local and systemic adverse effects. Microneedle (MN) patches loaded with micron-sized needle array, combining the advantages of oral administration and local injection, have become a potentially novel strategy for the administration and treatment of MSK diseases. In this review, we briefly introduce the basics of MNs and focus on the main characteristics of the MSK systems and various types of MN-based transdermal drug delivery (TDD) systems. We emphasize the progress and broad applications of MN-based transdermal drug delivery (TDD) for MSK systems, including osteoporosis, nutritional rickets and some other typical types of arthritis and muscular damage, and in closing summarize the future prospects and challenges of MNs application.

Menopausal hormone therapy and risk of dementia: health insurance database in South Korea-based retrospective cohort study

Introduction

Menopausal hormone therapy (MHT) is used to alleviate the symptoms associated with menopause, despite the lack of recommendations for MHT in preventing dementia. Recent nationwide studies have explored the association between MHT and dementia risk, but the findings remain limited. This study aims to investigate the association between MHT and the incidence of Alzheimer's disease (AD) and non-AD dementia using national population data from Korea.

Methods

We conducted a retrospective study using data from the National Health Insurance Service in Korea between January 1, 2002, and December 31, 2019. Women over 40 years were eligible for this study and classified into the MHT or non-MHT groups. The MHT group consisted of women who used Tibolone (TIB), combined estrogen plus progestin by the manufacturer (CEPM), estrogen, combined estrogen plus progestin by a physician (CEPP), and transdermal estrogen during menopause. We compared the risk of dementia between the MHT and non-MHT groups.

Results

The study included 1,399,256 patients, of whom 387,477 were in the MHT group, and 1,011,779 were in the non-MHT group. The median duration of MHT was 23 months (range: 10-55 months). After adjusting for available confounders, we found that different types of MHT had varying effects on the occurrence of dementia. TIB (HR 1.041, 95% confidence interval (CI) 1.01-1.072) and oral estrogen alone (HR 1.081, 95% CI 1.03-1.134) were associated with a higher risk of AD dementia. In contrast, there was no difference in the risk of AD dementia by CEPM (HR 0.975, 95% CI 0.93-1.019), CEPP (HR 1.131, 95% CI 0.997-1.283), and transdermal estrogen (HR 0.989, 95% CI 0.757-1.292) use. The use of TIB, CEPM, and oral estrogen alone increased the risk of non-AD dementia (HR 1.335, 95% CI 1.303-1.368; HR 1.25, 95% CI 1.21-1.292; and HR 1.128, 95% CI 1.079-1.179; respectively), but there was no risk of non-AD dementia in the other MHT groups (CEPP and topical estrogen).

Conclusion

Our findings indicate that MHT has varying effects on the incidence of AD and non-AD dementia. Specifically, TIB, CEPM, and oral estrogen alone increase the risk of non-AD dementia, while transdermal estrogen is not associated with dementia risk. It is essential to consider the type of MHT used when assessing the risk of dementia in women.

Menopausal hormone therapy and change in physical activity in the Women's Health Initiative hormone therapy clinical trials

OBJECTIVE

The menopausal transition results in a progressive decrease in circulating estrogen levels. Experimental evidence in rodents has indicated that estrogen depletion leads to a reduction of energy expenditure and physical activity. It is unclear whether treatment with estrogen therapy increases physical activity level in postmenopausal women.

METHODS

A total of 27,327 postmenopausal women aged 50-79 years enrolled in the Women's Health Initiative randomized double-blind trials of menopausal hormone therapy. Self-reported leisure-time physical activity at baseline, and years 1, 3, and 6 was quantified as metabolic equivalents (MET)-h/wk. In each trial, comparison between intervention and placebo groups of changes in physical activity levels from baseline to follow-up assessment was examined using linear regression models.

RESULTS

In the CEE-alone trial, the increase in MET-h/wk was greater in the placebo group compared with the intervention group at years 3 ( P = 0.002) and 6 ( P < 0.001). Similar results were observed when analyses were restricted to women who maintained an adherence rate ≥80% during the trial or who were physically active at baseline. In the CEE + MPA trial, the primary analyses did not show significant differences between groups, but the increase of MET-h/wk was greater in the placebo group compared with the intervention group at year 3 ( P = 0.004) among women with an adherence rate ≥80%.

CONCLUSIONS

The results from this clinical trial do not support the hypothesis that estrogen treatment increases physical activity among postmenopausal women.

Topical estrogens for the treatment of superficial dyspareunia related to genitourinary syndrome of menopause in women with a history of endometriosis: A clinical dilemma

Estrogen withdrawal, which occurs with the cessation of ovulation, causes genitourinary syndrome of menopause in up to 50-85% of women. Symptoms may profoundly impact quality of life and sexual function, interfering with enjoyment of sex in up to three out of four individuals. Topical estrogens have been found to provide symptom relief with minimal systemic absorption and appear to be superior to systemic therapy as what regards genitourinary symptoms. However, conclusive data on their appropriateness in postmenopausal women with a history of endometriosis is not available and the hypothesis that exogenous estrogen stimulation may reactivate endometriotic foci or even promote their malignant transformation is still open. On the other hand, endometriosis affects around 10% of premenopausal women, many of which may be exposed to an acute hypoestrogenic depletion even before spontaneous menopause occurs. This considered, excluding on principle patients with a history of endometriosis from first-line treatment for vulvovaginal atrophy would mean excluding a considerable percentage of the population from adequate care. More robust evidence is urgently needed in these regards. Meanwhile, it would appear reasonable to tailor the prescription of topical hormones in these patients, taking into account the entity of symptoms and the impact such symptoms have on patients' quality of life, as well as the form of endometriosis and the possible risks hormonal may entail. Moreover, the application of estrogens on the vulva instead of the vagina could be efficacious, while outweighing the possible biological cost of hormonal treatment in women with a history of endometriosis.

Therapeutic Effects of Vitamin D on Vaginal, Sexual, and Urological Functions in Postmenopausal Women

Recent years have witnessed the emergence of growing evidence concerning vitamin D's potential role in women's health, specifically in postmenopausal women. This evidence also includes its connection to various genitourinary disorders and symptoms. Numerous clinical studies have observed improvements in vulvovaginal symptoms linked to the genitourinary syndrome of menopause (GSM) with vitamin D supplementation. These studies have reported positive effects on various aspects, such as vaginal pH, dryness, sexual functioning, reduced libido, and decreased urinary tract infections. Many mechanisms underlying these pharmacological effects have since been proposed. Vitamin D receptors (VDRs) have been identified as a major contributor to its effects. It is now well known that VDRs are expressed in the superficial layers of the urogenital organs. Additionally, vitamin D plays a crucial role in supporting immune function and modulating the body's defense mechanisms. However, the characterization of these effects requires more investigation. Reviewing existing evidence regarding vitamin D's impact on postmenopausal women's vaginal, sexual, and urological health is the purpose of this article. As research in this area continues, there is a potential for vitamin D to support women's urogenital and sexual health during the menopausal transition and postmenopausal periods.

Hormone therapy for sexual function in perimenopausal and postmenopausal women

BACKGROUND

The perimenopausal and postmenopausal periods are associated with many symptoms, including sexual complaints. This review is an update of a review first published in 2013.

OBJECTIVES

We aimed to assess the effect of hormone therapy on sexual function in perimenopausal and postmenopausal women.

SEARCH METHODS

On 19 December 2022 we searched the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Science, two trials registries, and OpenGrey, together with reference checking and contact with experts in the field for any additional studies.

SELECTION CRITERIA

We included randomized controlled trials that compared hormone therapy to either placebo or no intervention (control) using any validated assessment tool to evaluate sexual function. We considered hormone therapy: estrogen alone; estrogen in combination with progestogens; synthetic steroids, for example, tibolone; selective estrogen receptor modulators (SERMs), for example, raloxifene, bazedoxifene; and SERMs in combination with estrogen.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. We analyzed data using mean differences (MDs) and standardized mean differences (SMDs). The primary outcome was the sexual function score. Secondary outcomes were the domains of sexual response: desire; arousal; lubrication; orgasm; satisfaction; and pain. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 36 studies (23,299 women; 12,225 intervention group; 11,074 control group), of which 35 evaluated postmenopausal women; only one study evaluated perimenopausal women. The 'symptomatic or early postmenopausal women' subgroup included 10 studies, which included women experiencing menopausal symptoms (symptoms such as hot flushes, night sweats, sleep disturbance, vaginal atrophy, and dyspareunia) or early postmenopausal women (within five years after menopause). The 'unselected postmenopausal women' subgroup included 26 studies, which included women regardless of menopausal symptoms and women whose last menstrual period was more than five years earlier. No study included only women with sexual dysfunction and only seven studies evaluated sexual function as a primary outcome. We deemed 20 studies at high risk of bias, two studies at low risk, and the other 14 studies at unclear risk of bias. Nineteen studies received commercial funding. Estrogen alone versus control probably slightly improves the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.50, 95% confidence interval (CI) (0.04 to 0.96; I² = 88%; 3 studies, 699 women; moderate-quality evidence), and probably makes little or no difference to the sexual function composite score in unselected postmenopausal women (SMD 0.64, 95% CI -0.12 to 1.41; I² = 94%; 6 studies, 608 women; moderate-quality evidence). The pooled result suggests that estrogen alone versus placebo or no intervention probably slightly improves sexual function composite score (SMD 0.60, 95% CI 0.16 to 1.04; I² = 92%; 9 studies, 1307 women, moderate-quality evidence). We are uncertain of the effect of estrogen combined with progestogens versus placebo or no intervention on the sexual function composite score in unselected postmenopausal women (MD 0.08 95% CI -1.52 to 1.68; 1 study, 104 women; very low-quality evidence). We are uncertain of the effect of synthetic steroids versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 1.32, 95% CI 1.18 to 1.47; 1 study, 883 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 0.46, 95% CI 0.07 to 0.85; 1 study, 105 women; very low-quality evidence). We are uncertain of the effect of SERMs versus control on the sexual function composite score in symptomatic or early postmenopausal women (MD -1.00, 95% CI -2.00 to -0.00; 1 study, 215 women; very low-quality evidence) and of their effect in unselected postmenopausal women (MD 2.24, 95% 1.37 to 3.11 2 studies, 1525 women, I² = 1%, low-quality evidence). We are uncertain of the effect of SERMs combined with estrogen versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.22, 95% CI 0.00 to 0.43; 1 study, 542 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 2.79, 95% CI 2.41 to 3.18; 1 study, 272 women; very low-quality evidence). The observed heterogeneity in many analyses may be caused by variations in the interventions and doses used, and by different tools used for assessment.

AUTHORS' CONCLUSIONS

Hormone therapy treatment with estrogen alone probably slightly improves the sexual function composite score in women with menopausal symptoms or in early postmenopause (within five years of amenorrhoea), and in unselected postmenopausal women, especially in the lubrication, pain, and satisfaction domains. We are uncertain whether estrogen combined with progestogens improves the sexual function composite score in unselected postmenopausal women. Evidence regarding other hormone therapies (synthetic steroids and SERMs) is of very low quality and we are uncertain of their effect on sexual function. The current evidence does not suggest the beneficial effects of synthetic steroids (for example tibolone) or SERMs alone or combined with estrogen on sexual function. More studies that evaluate the effect of estrogen combined with progestogens, synthetic steroids, SERMs, and SERMs combined with estrogen would improve the quality of the evidence for the effect of these treatments on sexual function in perimenopausal and postmenopausal women.

Timing of hormone therapy and its association with cardiovascular risk and metabolic parameters in 4-vinylcyclohexene diepoxide-induced primary ovarian insufficiency mouse model

OBJECTIVE

To evaluate the effects of various initiation time points and durations of hormone therapy (HT) on cardiovascular and metabolic parameters of premenarche, primary ovarian insufficiency (POI) mouse model, induced by 4-vinylcyclohexene diepoxide.

METHODS

A total of 50 mice at 4 weeks of age were developed into POI mouse model, further randomly categorized into 5 groups: control group without any intervention; no HT group with only high-fat diet (NT); group 1 with delayed estradiol treatment (T1); group 2 with on-time, continuous estradiol treatment (T2); and group 3 with on-time estradiol treatment but early stop (T3). Cardiovascular risk and metabolic parameters were measured.

RESULTS

Presenting with similar body weights, blood glucose levels of T1, T2, and T3 were all significantly lower than NT (p < .001). Serum total cholesterol and insulin were also significantly lower in all HT groups than in NT, especially in T2 (p < .001). For serum low-density lipoprotein-cholesterol, only T2 resulted in the statically lower level than those of NT, T1, and T3 (p < .001). Aortic thickness was significantly increased with aggravated fibrotic change of the intima in NT, and such consequence was significantly ameliorated in HT groups, mostly lowered in T2 (p < .05). Last, serum pro-inflammatory cytokines were significantly low in the HT groups than in NT, especially in T2 with the lowest level (p < .05). .

CONCLUSIONS

On-time, continuous E2 treatment immediately after a biologic estrogen deprivation event significantly reduced metabolic and cardiovascular risks in young, pre-menarche female mouse models of POI, confirming decreased serum levels of pro-inflammatory cytokines.

Management of perimenopausal and menopausal symptoms

Most women worldwide experience menopausal symptoms during the menopause transition or postmenopause. Vasomotor symptoms are most pronounced during the first four to seven years but can persist for more than a decade, and genitourinary symptoms tend to be progressive. Although the hallmark symptoms are hot flashes, night sweats, disrupted sleep, and genitourinary discomfort, other common symptoms and conditions are mood fluctuations, cognitive changes, low sexual desire, bone loss, increase in abdominal fat, and adverse changes in metabolic health. These symptoms and signs can occur in any combination or sequence, and the link to menopause may even be elusive. Estrogen based hormonal therapies are the most effective treatments for many of the symptoms and, in the absence of contraindications to treatment, have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause. Non-hormonal treatment options are also available. Although a symptom driven treatment approach with individualized decision making can improve health and quality of life for midlife women, menopausal symptoms remain substantially undertreated by healthcare providers.