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Menopause. Subjective Findings and History 10,11. ICD-10 Codes: Origination Date: 1996 Review/Revised Date: 01/2018 Next Review Date: 01/2020

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Menopause

Diagnosis/Condition:

Menopause

Discipline:

Integrated

ICD-10 Codes:

N95

Origination Date:

1996

Review/Revised Date:

01/2018

Next Review Date:

01/2020

Menopause is a normal physiological event, not a disease. As a result, health care interventions

cannot be thought of as being “curative,” but rather as being intended to assist a woman through

this stage of her life. It represents the transition from her reproductive phase, which begins with

the first menstrual period (menarche), to the beginning of perimenopause (aka climacteric,

menopause transition, change of life) which is the beginning of the physiologic changes leading

over time to complete ovarian failure and the final menstrual period. Menopause is the complete

cessation of menses and is often used interchangeably with post-menopause which is the time

from last menstrual period to the end of life.

1

,

2

,

3

The presence of menopause is confirmed after one year without a menstrual cycle (amenorrhea);

symptoms may start about four years before menses cease (perimenopause). The permanent

cessation of menstruation follows the loss of ovarian activity, resulting in complete or near

complete, ovarian follicular depletion, resulting in lower levels of estrogen and other hormones,

with high follicle-stimulating hormone (FSH) concentrations.

4

Menopause can occur naturally, as

a result of aging, or secondary to surgery, medications, or radiation. The 5-year period after the

final menstrual period is considered early post-menopause.

5

The impact on the individual and on society, is considerable. Approximately 60% of women of

ages 45-60 report accessing health care services (both conventional and integrative medicine) and

the proportion increased with age. Typical treatments such as hormone therapy incompletely

resolve the symptoms. Population surveys show significant use of integrative health to manage

menopause.

6

,

7

Costs associated with menopause symptoms include the direct cost of medical care

and the cost of reduced productivity, absenteeism, and diminished physical and social

functioning.

8

,

9

Subjective Findings and History

10,11

Symptoms associated with menopause vary considerably between individuals, racial and

ethnic groups, and the particular stage of the woman’s menopause transition. Some women

pass through the stages of menopause easily while a significant percentage find the

problems ranging from bothersome to disabling.

(2)

early menopause (at age 41-45 years) or premature menopause (at age 40 years or

younger).

12

Body systems of significance in menopause include: cardiovascular, sexual and reproductive

(urogenital), musculoskeletal, mental/emotional, and dermatological.

Common symptoms include: vasomotor instability (hot flashes, night sweats, sleep

disturbances), irregular, heavy or light menses, palpitations, decreased libido, skin changes,

headaches (including migraines), memory loss and decreased mental concentration, muscle

and joint pain, mood changes (anxiety, jealousy, emotional lability, nervousness, depression,

insomnia, irritability), and genitourinary (GU) symptoms (vaginal dryness, dysuria, urinary

tract infections (UTI), post-coital bleeding). Symptoms are often most severe during early

post-menopause. Perimenopause can also include menorrhagia and dysmenorrhea.

These symptoms can be diagnosed or tracked using one or more validated clinical research

tools: Menopause Rating Scale (MRS)

13

, the Kupperman Index (KMI)

14

, and The

Menopause-Specific Quality of Life (MENQOL) Questionnaire.

15

Based on the data from

cohort studies, the Stages of Reproductive Aging (STRAW) staging system has been

developed and is considered to be the gold standard for characterizing reproductive aging

from the reproductive years through menopause.

16

Hot flashes and flushing are prevalent symptoms and the most common reason women seek

medical care.

10

In addition to acute symptoms, estrogen deficiency may also lead to long-term

health risks such as increased risk of osteoporosis (with accelerated bone loss) and

cardiovascular disease.

The symptoms associated with menopause are often non-specific to the hormonal changes of

menopause and may be caused by other medical conditions, behavioral health issues, or

adverse medication effects.

17

In a small sample of Turkish women with fibromyalgia (chronic wide spread pain) found a

positive association between the menstrual cycle in premenopausal women and their level of

pain. Post-menopausal subjects had increased levels of pain and about 25% of these women

had the onset of their chronic pain with the onset of menopause.

18

Objective Findings

Objective findings from perimenopause through post-menopause may include: elevated

blood pressure, symptoms of anemia (fatigue), changes in menstruation, mood changes,

sleep disorders, evidence of UTI, atrophic vaginitis, and diaphoresis (vasomotor symptoms).

Assessment

Complete physical and pelvic (gynecological) examinations are recommended.

A physical exam, including vitals, body mass index (BMI), dental evaluation, ophthalmic

evaluation (assessing for macular degeneration), cardiovascular, dermatological (skin, hair

and nail health), and mental health screening are suggested.

Lab evaluations: Serum FSH and LH change and eventually become elevated; estrogen and

progesterone levels increase, and then eventually decrease. Anemia may be present. Blood

chemistries may be indicated to assess lipid status and thyroid function. FSH, LH, and

(3)

serum estradiol may be evaluated to assist with response to treatment.

Assessment of cardiovascular risk: lipid profile recommended, may require in-depth

evaluation to assess risk.

Colorectal screening, DEXA (bone density testing), and mammography as needed based on

risk factors and age screening guidelines. (Screening guidelines for patients of all ages can be

found at the Agency for Healthcare Research and Quality)

19

Pap smear schedule should be current; maturation index may provide information on

hormone levels in relation to squamous epithelial cells.

Note: Women under age 40 with irregular menses, or women of any age with atypical hot

flashes, or heavy bleeding should be assessed for other contributing factors and causes

(including endocrine disorders, medications, pregnancy, malignancy, and ovarian failure).

Treatment

Treatment goals: Focus on alleviation of symptoms to improve quality of life and prevention of

long term risk factors related to cardiovascular disease, osteoporosis, and dementia. Research has

shown that women feel they are not sufficiently informed to make safe decisions regarding

integrative healthcare (IH) treatment options to alleviate menopausal symptoms. With the

increased adoption of IH, it is important for health care providers to be familiar with treatments

used by patients for symptoms of menopause, so they are comfortable discussing the benefits and

risks with their patients to assist them in making informed decisions.

20,21

Increased clinician

awareness can promote supportive discussions about evidence-based IH during health

counseling for menopause.

22,23, 24

Therapies

Vitamin/mineral supplementation:

Calcium/Vitamin D – shown to reduce bone mineral density loss, and the incidence of

fractures in postmenopausal women.

206

Magnesium and boron.

25

Vitamin C and hesperidin.

26,27,28

Vitamin E

29,30,31,32,33,34,35,36,37,38

- Vitamin E in excessive amounts has been shown to be associated

with increased all-cause mortality.

39

Vitamins A, and K, magnesium, selenium and zinc - These vitamins, minerals and trace

elements play an important role in maintaining health and wellbeing among menopausal

women.

40

Botanical medicines

: including phytohormone precursors, hormonal support and balancing herbs,

nervines, digestive tonics, and liver supporting herbs.

41

Cimicifuga racemosa

(

Actaea racemosa

) or black cohosh - mixed results for vasomotor

symptoms.

42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,6465,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,39, 48,82,83,84,85,86,87,70,206

For sleep and mood issues related to vasomotor symptoms.

45
(4)

Data points to better efficacy in perimenopause.

88

Pockaj et al. (2004) suggested that black

cohosh may be of benefit to women with breast cancer who are taking tamoxifen, because of

its presumed serotonergic rather than estrogenic effect.

84,89

Black cohosh interacts with a

CYP34A, which may potentiate drug interactions.

39

There are positive studies based on the MRS and the KMI.

90,91

There is no evidence to date to suggest any safety issues or contraindications for the use of black

cohosh (

C. racemosa

)

in women with previous breast cancer.

92,93

There were earlier concerns about

potential phytoestrogenic activity of black cohosh, but more recent research indicates that the

mechanism of action is not estrogenic.

22,94,95

Many medical providers have not updated their clinical

practice to match current evidence. Studies are ongoing to further examine this issue.

96

Asian Ginseng (

Panax

)

97

Mixed results for vasomotor symptoms and somatic complaints

(fatigue, insomnia, depression, mood).

98,99,100,101

Of note: case reports have linked ingestion of

ginseng with post-menopausal bleeding and potentiating warfarin therapy.

102,103,104

Red Ginseng.

105

Kava (

Piper methysticum

).

106,107,108

Kudzu.

Hops (

Humulus lupulus

).

Rhubarb (

Rheum rhabarbarum).

Pycnogenol (Pine bark).

109,110

Lepididium meyenii (Maca).

110

Ginkgo (

Ginkgo biloba

).

111,112,113,114,115,116,117,118,119,120,121

Licorice (

Glycyrrhiza glabra

).

122,123,124

(

Trifolium pratense

) isoflavones for urogenital symptoms (dyspareunia, vaginal dryness,

decreased libido)

125,126,127,128,129,130,131132

, mixed results for vasomotor Symptoms.

133,134,135,136,137,138,139

Rehmannia spp.

140,141,142,143,144,145,146,147

Sage (

Salvia

officinalis

).

148,149,150,151152,153

Saint John's Wort (

Hypericum perforatum

).

154,155,156,157,158,159

Dong quai (

Angelica sinensis

) - considered to be a valuable herb in multi-botanical

formulations

160,161,162163,164,165,166,167,168,169,170,171172,173

mixed results. The estrogenic profile of dong

quai has been conflicting and caution should be used until more research has been

conducted on long-term effects.

174,175

Evening Primrose Oil - mixed results for vasomotor symptoms.

176,177

May be effective for

cardiovascular and bone health.

,39

Soy Isoflavones

178,179180,181,182,183,184,185,186,187,188,138,189,190,191,192

- mixed results for vasomotor

symptoms,

193,39,194,195,196,138

a diet high in soy protein was found to be protective against bone

fracture, with a trend toward lower risk with higher soy intake,

197,186,195

some evidence for

effects on arterial compliance, decreasing LDL, and increasing HDL. High doses of isolated

genistein reduce the frequency/intensity of hot flashes while low doses of genistein show no

significant effect.

198
(5)

Phytoestrogens

199,200,201,202,203

- there is no evidence to date to suggest any serious safety

concerns associated with phytoestrogens intake in healthy women.

204,205

These appear to have

only minimal effect on hot flashes but have other positive health effects, e.g. on plasma lipid

levels and bone loss.

206

Phytosterols (PS) and phytostanols (PS) have been shown to diminishing LDL and total

cholesterol in postmenopausal women.

206

PS possess further beneficial properties including

anti-inflammatory, anti-atherogenic, antioxidant, and anti-cancer effects.

207

Vitex (Chasteberry) (

Vitex agnus-castus

)

208.209210,211,212,213,214,215,216,217,218,219,220,221,222,223,224,225,226

Wild Yam (

Dioscorea villosa

)

123,227,228,229,230,231,39,110

- mixed results in studies.

Combination Herbal Formulas.

123,232,233,87,234

o

Cimicifuga

with St. John’s Wort – shown to be effective for vasomotor symptoms.

235

o

EstroG-100 (

Cynanchum wilfordii, Phlomis umbrosa and Angelica gigas

).

236

o

Chinese herbal mixtures.

237

Homeopathic medicine:

- based on case and symptoms

238

Acupuncture:

Research has shown mixed results for reduction of vasomotor symptoms.

239,240,194,241,242,243,244,245,246,247,248

Acupuncture for sleep.

249,250,251

A metanalysis of acupuncture RCTs showed benefit for improved quality of life, hot flash

frequency and severity, and other menopausal symptoms.

252

A more recent evidence report from the VA Health Services Research& Development

Service concluded that while the evidence is of low to moderate quality, it does show that

compared to waitlist controls, acupuncture (and yoga) reduced the impact of hot flushes

and other symptoms on quality of life.

253

A 2018 systematic review and meta-analysis found evidence from RCTs that supports the

use of acupuncture as an adjunctive or stand-alone treatment for reducing hot flushes and

improving health related quality of life. As with other studies of acupuncture, identifying

specific versus non-specific effects is difficult.

254

Physical medicine approaches

Chiropractic:

Evidence supporting the use of spinal manipulation specifically for menopause is generally

lacking. However, the relationship of musculoskeletal pain complaints to menopause is

emerging. An observational study of postmenopausal women revealed that the most common

pain problems were headaches, joint/bone pain, and spine pain. Some of the women

experienced relief of these symptoms in the postmenopausal state, while others experienced the

opposite.

255

Many of the symptoms associated with menopause can be effectively and safely

treated by chiropractors. Referral for chiropractic consultation may be appropriate for women

who present with musculoskeletal symptoms.

(6)

Bone and joint pain. Joint pain is common among women of the age around

menopause. Hormone replacement has been shown to reduce, but not eliminate it.

Differentiating joint pain due to estrogen deficiency versus joint pain due to other causes

such as age-related degenerative joint disease for example, is difficult.

256

Joint pain due

to dysfunction may be amenable to chiropractic treatment. See Clinical Compass.org for

evidence summaries of manual and exercise therapies for upper and lower extremity

joint pain.

Low back pain (LBP). LBP is a common complaint associated with the transition

through to menopause. While the causation of back pain by the physiology of

menopause is obscure, research suggests that menopause increases a woman’s risk of

this complaint.

257

,

258

The literature support for chiropractic care for low back pain is

robust (see relevant CHP Clinical pathways).

Headache. Headache is a common symptom among all persons. Headache associated

with menstrual cycle, perimenopause, menopause, and post menopause are also well

known, but poorly understood. Attempts to discover links between fluctuating

hormone levels and headache are inconclusive. Clinically, some women who suffer

headaches associated with menses in their younger years stop having them at

menopause, while in others it is just the opposite. Hormone replacement therapy

appears to benefit some women but aggravates headache in others.

259

Non-pharmacologic approaches to headache may be appropriate and evidence-based

guidelines recommend spinal manipulation as an effective treatment for headaches.

260

Pelvic pain. (maybe later)

Massage Therapy:

A survey shows that several women between ages 45-65 use Massage Therapy an

effective way to combat some of the symptoms of menopause

261

.

Massage Therapy has proven to help menopausal women with Sleep disturbances

(insomnia), Depression and help with overall Quality of Life.

262

Stress has been shown to increase the symptoms of Menopause and even increase the

age of onset

263

and Massage therapy has been proven to be very beneficial in reducing

stress,

264265266

and promoting relaxation. Massage Therapy can also help relieve chronic

headaches.

267

Regular muscle and joint pain can be managed extremely effectively with Massage

Therapy.

268

There is knowledge that Reflexology, Acupressure and Swedish Massage can help

regulate the body’s fluid balance and restore hormone balance.

269270

It has also been shown that Massage Therapy can reduce both menopausal and

psychological symptoms related to menopause. It is even more effective when coupled

with Aromatherapy.

271272
(7)

Exercise therapy and strength training:

A recent survey of over 5000 Australian women suggested that exercise, from even low

levels of physical activity, is associated with fewer complaints of joint pain in middle

aged women. However improved symptoms were not related to menopausal status.

273

This suggests that the benefits of exercise are good in general for postmenopausal

women.

A study from Finland reported on 647 women age 48-55 years and found no relationship

between current levels of physical activity and menopause symptoms. However, there

was a negative association with pelvic floor complaints (e.g. urinary incontinence) were

more common in women with low levels of physical activity.

274

Exercise may be beneficial for some of the chronic sequelae of menopause. Studies have

shown that exercise enhances bone strengthening and improves cardiovascular

health

275,290,276,277,278,279,

280,281

as well as reducing bone mineral density loss and the incidence of fractures in

postmenopausal

Women.

206

Other non-specific effects of exercise include improved mood, quality of life, and

memory/concentration.

282

,

283

,

284

,

285

Life style factors and modifications:

Smoking (negative correlation).

286,287,288,289

Wearing light clothing, weight reduction, and yoga (for vasomotor symptoms).

290,291

Dietary changes:

fiber is effective in reducing serum total cholesterol in hypercholesterolemic

postmenopausal women.

206

Mind-Body Therapies: -

(yoga, meditation, tai chi, muscle relaxation, breath-based techniques,

relaxation response training and low-frequency sound-wave therapy). In a systematic review,

there was improvement in overall menopausal and vasomotor symptoms; six of seven trials

indicated improvement in mood and sleep with yoga-based programs (include 295 ref.), and

four studies reported reduced musculoskeletal pain. Results from the remaining nine trials

suggest that breath-based and other relaxation therapies also show promise for alleviating

vasomotor and other menopausal symptoms.

292,293,294,295

Clinical Hypnosis

296

Qigong

297

Pharmaceuticals:

Clonidine – for vasomotor symptoms.

138,45

Gabapentin – for vasomotor symptoms.

298,299,300

Selective serotonin reuptake inhibitors (SSRIs)- for vasomotor symptoms,

301,302,303,304,305
(8)

Bio-identical hormone replacement therapy (BHRT) and hormone replacement therapy (HRT):

- based on

patient preference and symptoms, with appropriate risk factor assessment and monitoring, with

an informed discussion of these factors.

307,308,309,310

BHRT and HRT are medications with different chemical structures: -

most clinical trials have been

done using HRT only (conjugated equine estrogens synthesized from the urine of pregnant

mares, either alone (as Premarin) or with the progestin medroxyprogesterone acetate (as

Prempro). BHRT is thought to be a safer alternative to HRT, but research is lacking to definitively

demonstrate this and data are not available.

311

As in all prescribing, individual risk factors must

be assessed and PARQ with patients provided for ethical and effective medical care.

312,313

o

Once thought to be cardio-protective, more recent prospective trials demonstrated a

potential increase in cardiovascular events in addition to an increased risk of breast

cancer, raising concerns over the use of HRT.

314

The highly publicized results of these

trials initiated concerns with the lay public and, ultimately, changed professional

prescribing patterns with the use of HRT in the United States decreasing from 91

million users in 2001 to 57 million in 2003.

315

(Natural progesterone transdermal or

oral).

316,317,318,319,320,321,322,323,324,325,326

o

DHEA.

327,328,329,330,331,332

o

Estrogen (transdermal, oral, vaginal).

333

o

Progesterone (micronized)

334

o

Selective estrogen receptor modulator (SERM) – ospemifene (for dyspareunia due

to menopausal atrophy)

o

Tissue-selective estrogen complex (TSEC) – tibolone

The International Menopause Society highlights the benefits and effectiveness of menopausal

hormone therapy (MHT) outweighing the risks for symptomatic women before the age of 60

years or within 10 years after menopause. However, evidence suggests an increased risk of

heart disease, stroke and breast cancer in the 60s and 70s age groups. MHT should never be

stopped abruptly and it is recommended there is gradual reduction before cessation.

335

MHT

may be unsuitable women at increased risk of cardiovascular disease, thromboembolic disease

(such as those with obesity or a history of venous thrombosis) or some types of cancer (such as

breast cancer, in women with a uterus). The risk of endometrial cancer among women with a

uterus taking estrogen-only MHT is well documented.

336

Psychosocial:

Treatment of mental health and emotional symptoms.

Case appropriate counseling (e.g. contraception, emotional issues, transitions, sexual

concerns, progression, and medical issues at menopause).

Cognitive Behavioral Therapy (CBT).

337,338,339,340,341

Length of Treatment

(9)

Criteria for Referral or Re-evaluation

Development of other gynecological conditions beyond range of “simple” menopause.

Evidence of other age or hormone related organ system problems: moderate to severe

bone loss, symptoms of dementia or moderate-severe depression, evidence of coronary

artery disease, macular degeneration, cancers, and gastrointestinal disease.

Resources for Clinicians

Systematic Reviews

National Institutes of Health and Care Excellence (NICE). NICE guidance on Diagnosis and

Management of Menopause, November 2015.

Shifren JL, Gass ML.

NAMS Recommendations for Clinical Care of Midlife Women Working

Group

.

Menopause.

2014 Oct;21(10):1038-62.

Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position

statement of The North American Menopause Society. Menopause. 2015;22(11):1155-72.

De villiers TJ, Hall JE, Pinkerton JV, et al. Revised global consensus statement on menopausal

hormone therapy. Maturitas. 2016;91:153-5.

Proposed: AHRQ. Evidence-based Practice Center Systematic Review Protocol. Project Title:

Menopausal Symptoms: Comparative Effectiveness Review of Therapies. March, 2015. Accessed

Dec 18th, 2017 at

https://effectivehealthcare.ahrq.gov/topics/menopause/research

Cobin RH, Goodman NF. American association of clinical endocrinologists and American

college of endocrinology position statement on menopause-2017 update. Endocr Pract.

2017;23(7):869-880.

Society for Acupuncture Research. Acupuncture for the Management of Menopausal

Symptoms: An Overview of Research. December 2017.

www.AcupunctureResearch.org

.

Clinical Pathway Feedback

CHP desires to keep our clinical pathways customarily updated. If you wish to provide

additional input, please click on the email address listed below and identify which clinical

pathway you are referencing. Thank you for taking the time to give us your comments.

Clinical Services Department:

providers@chpgroup.com

Disclaimer Notice

The CHP Group (CHP) Clinical Pathways are a resource to assist clinicians and are not intended

to be nor should they be construed/used as medical advice. The pathways contain information

(10)

that may be helpful for clinicians and their patients to make informed clinical decisions, but

they cannot account for all clinical circumstances. Each patient presents with specific clinical

circumstances and values requiring individualized care which may warrant adaptation from

the pathway. Treatment decisions are made collaboratively by patients and their practitioner

after an assessment of the clinical condition, consideration of options for treatment, any material

risk, and an opportunity for the patient to ask any questions.

CHP makes no representation and accepts no liability with respect to the content of any external

information cited or relied upon in the pathways. The presence of a particular procedure or

treatment modality in a clinical pathway does not constitute a representation or warranty that

this service is covered by a patient’s benefit plan. The patient’s benefit plan determines

coverage.

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