Introduction
In celebration of the 25th anniversary of The North American Menopause Society (NAMS), the Society has compiled a set of key points and clinical recommendations for the care of midlife women. NAMS has always been a premier source of information about menopause for both healthcare providers and midlife women. At this special time in the history of the Society, we wished to provide a succinct guide to improve the understanding and management of women's health at this critical stage of life. In addition to covering the key topics of vasomotor symptoms, osteoporosis, and vulvovaginal health, this guide includes information and recommendations for care on more than 50 important topics, including sexual function, cognition, cardiovascular health, thyroid disease, and cancers. Additional sections review basic physiology, counseling issues, screening tests, and complementary and alternative medicine.
The basis for these key points and clinical recommendations is the NAMS premier textbook, Menopause Practice: A Clinician's Guide. Published originally in 2000 and updated approximately every three years to remain current, this clinical practice textbook provides in-depth coverage of all areas of interest to clinicians who care for women at midlife. Each topic is written by an expert in the field, including internationally recognized gynecologists, internists, medical and reproductive endocrinologists, cardiologists, neurologists, psychiatrists, psychologists, dermatologists, oncologists, and counselors. Relevant research is described in detail, and each topic is accompanied by an extensive list of references. NAMS Recommendations for the Clinical Care of Midlife Women, published in this edition of Menopause, will be freely available on the NAMS website to promote high-quality care for women throughout the world. These recommendations provide a brief overview of each topic presented in the textbook. Clinicians who wish to learn more about a given topic area, review relevant research, and access related references are encouraged to expand their knowledge by purchasing Menopause Practice: A Clinician's Guide, 5th edition, available through the NAMS website.
NAMS Recommendations for the Clinical Care of Midlife Women was developed by asking each author of every section of the textbook to submit a brief summary of their topic, including several key points and recommendations for clinical care. Each topic was carefully reviewed, edited, and approved by an Editorial Panel, with final review and approval by the 2013-2014 NAMS Board of Trustees. The Editorial Panel was comprised of experts in midlife women's health from a wide range of specialties who devoted significant time and effort to ensuring the accuracy and relevance of each key point and clinical recommendation. Every clinical recommendation is accompanied by a level of evidence, and the strength of each recommendation is based on the highest level of evidence found in the data.
Recommendations are provided and graded according to the following categories:
Level I—based on good and consistent scientific evidence.
Level II—based on limited or inconsistent scientific evidence.
Level III—based primarily on consensus and expert opinion.
We hope that these evidence-based recommendations will be a valuable resource for clinicians and further the mission of NAMS, at its 25th anniversary, to promote the health and quality of life of all women during midlife and beyond.
Jan L Shifren, MD, NCMP
President, NAMS
Editor-in-Chief, NAMS Recommendations for the Clinical Care of Midlife Women
Margery LS Gass, MD, NCMP
Executive Director, NAMS
Editor, NAMS Recommendations for the Clinical Care of Midlife Women
Table of Contents
CHAPTER 1: MENOPAUSE
Overview of menopause
Ovarian aging and hormone production
Premature menopause and primary ovarian insufficiency
CHAPTER 2: MIDLIFE BODY CHANGES
Vulvovaginal changes
Body weight
Skin
Hair
Eyes
Ears
Teeth and oral cavity
CHAPTER 3: CLINICAL ISSUES
Decline in fertility
Uterine bleeding
Vasomotor symptoms
Genitourinary syndrome of menopause/Symptomatic vulvovaginal atrophy
Urinary incontinence
Sexual function
Sleep disturbance
Headache
Cognition
Psychological symptoms
Sexually transmitted infections
CHAPTER 4: DISEASE RISK
Cardiovascular health
Diabetes mellitus
Osteoporosis
Gallbladder disease
Arthritis and arthralgia
Thyroid disease
Epilepsy
Asthma
Breast cancer
Endometrial cancer
Cervical cancer
Ovarian cancer
Lung cancer
Colorectal cancer
Pancreatic cancer
Skin cancer
CHAPTER 5: CLINICAL EVALUATION AND COUNSELING
History and physical exam
Diagnostic and screening tests
Counseling issues
Quality-of-life assessment tools
CHAPTER 6: COMPLEMENTARY AND ALTERNATIVE MEDICINE
Integrative medicine
Herbs
CHAPTER 7: NONPRESCRIPTION OPTIONS
Government regulations for dietary supplements
Vitamins and minerals—calcium
Vitamins and minerals—vitamin D
Vitamins and minerals—magnesium
Other vitamins and minerals
Other supplements
Over-the-counter hormones
CHAPTER 8: PRESCRIPTION THERAPIES
Contraceptives
Estrogen therapy and estrogen-progestogen therapy
Compounded hormone therapy
Androgens
Selective estrogen receptor modulators
Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors