Menopause Live - IMS Updates

Date of release: 30 March, 2009

Approach to the patient with menopausal symptoms

Using a case history of a patient with classical menopausal symptoms, Martin and Manson have recently reviewed in brief the recent data and controversies over hormone replacement therapy (HRT) and discussed hormonal regimens (oral, transdermal) and dosage, duration of therapy and alternative treatment options [1]. The main motif of the article is safety, namely, how to balance the potential benefits of HRT against the potential risks in early and late menopause, and ways to identify patients in whom this balance would be the most, or least, favorable. For example, the authors suggest to incorporate the Framingham Score (a tool for assessment of the 10-year risk for coronary heart disease) in decision-making and consider a cut-off point of higher than 20% risk in the first 5 years of menopause, or higher than 10% risk during years 6–10 after menopause as a negative argument for prescribing HRT.


In view of the updated guidelines and recommendations on HRT issued by American and European ObGyn or menopause societies [2-5], expressing views which come closer to the 2007 IMS opinion [6], it seems that there is a consensus that estrogen is the best and most effective option to treat vasomotor symptoms, and that there should not be a safety concern in healthy, young postmenopausal women during the first years of use. However, there is still a debate on the optimal duration of therapy and on safety issues concerning prolonged use. While most postmenopausal women suffer vasomotor symptoms for no more than several months or years, a minority may still experience them later in life or following withdrawal of HRT. For these cases, a decision tree to help the clinician to evaluate potential benefits and risks of long-term HRT seems important. Since the main risk items are breast cancer, thromboembolism and coronary heart disease, the prescribing physician has to address the relevant, individual risk profile and balance it with the severity of menopausal symptoms and its effect on quality of life. Potential prevention of fractures, especially in high-risk patients, should also be included in the benefit–risk equation. Thus, the question arises whether it is possible to easily assess the various components of the equation in the setting of a primary-care clinic. The list of risk factors for coronary heart disease, breast cancer and osteoporosis is well known, and several popular scoring systems for risk evaluation are being used (Framingham or SCORE for coronary heart disease, Gail for breast cancer, bone density and FRAX for fractures). However, a simple, integrative algorithm for initiation of HRT in the early menopause, as well as for women in a later phase of menopause, or for long-term users of HRT, has not been developed yet and seems necessary.


Amos Pines
Department of Medicine T, Ichilov Hospital, Tel-Aviv, Israel


  1. Martin KA, Manson JE. Approach to the patient with menopausal symptoms. J Clin Endocrinol Metab 2008;93:4567-75. Published December 2008.

  2. Utian WH, Archer DF, Bachmann GS, et al. Estrogen and progestogen use in postmenopausal women: July 2008 position statement of the North American Menopause Society. Menopause 2008;15:584602. Published July/August 2008.

  3. Practice Committee of the American Society for Reproductive Medicine. Estrogen and progestogen therapy in postmenopausal women. Fertil Steril 2008;90(Suppl 5):S88102. Published November 2008.

  4. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 420, November 2008: hormone therapy and heart disease. Obstet Gynecol 2008;112:118992. Published November 2008.

  5. Gompel A, Rozenberg S, Barlow DH, et al. The EMAS 2008 update on clinical recommendations on postmenopausal hormone replacement therapy. Maturitas 2008;61:22732. Published November 20, 2008.

  6. Board of the International Menopause Society, Pines A, Sturdee DW, Birkhäuser MH, et al. IMS updated recommendations on postmenopausal hormone therapy. Climacteric 2007;10:18194. Published June 2007.