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Menopause Care in Primary Care
Treating VMS as a Part of Menopause Care in Primary Care: A Call to Action

Released: April 08, 2024

Expiration: April 07, 2025

Gloria Richard-Davis
Gloria Richard-Davis, MD, MBA, NCMP, FACOG
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Key Takeaways

Menopause Symptoms: To Treat or Not to Treat
Menopause is considered to begin 12 months after a patient’s last menstrual period, and it is projected that there will be 90 million postmenopausal patients by 2060. Up to 80% of patients with menopause experience vasomotor symptoms (VMS), such as hot flashes and night sweats, which can occur several times in an hour and throughout the day. VMS can also occur prematurely in patients who have had estrogen loss secondary to hypogonadism, bilateral oophorectomy, or primary ovarian insufficiency. Menopause can also cause sleep disruption, vulvovaginal atrophy, difficulty concentrating, and short-term memory problems and is associated with depression, anxiety, fatigue, and social isolation. The multiethnic, multiracial SWAN study showed that patients experienced VMS for a median total length of 7.4 years and continued for a median of 4.5 years after the final menstrual period. Primary care providers are often the first point of contact for many patients seeking VMS relief and are tasked with providing short-term and long-term treatment plans. In 2002, after the Women’s Health Initiative (WHI) estrogen/progestin arm was closed, prescriptions for hormone therapy (HT) dropped by 80% and have never recovered. To date, up to 60% of patients seeking care for these symptoms remain untreated. Why might this be?

Studies have shown that medical training programs do not adequately provide learners with the foundational knowledge of menopause, limiting their ability to deliver optimal care to patients experiencing VMS. In 2021, Shrivastava and colleagues reported survey results of US medical residents revealing that they felt ill prepared to manage patients with menopause because of a lack of training in this area. Kling and colleagues found that although family medicine, internal medicine, and OB/GYN residents acknowledged the importance of menopause training, significant knowledge gaps about menopause care were evident. Ng and colleagues reported that increasing education on menopause improved healthcare professional (HCP) knowledge and confidence in managing patients in menopause. Therefore, education on the pathophysiology, clinical manifestations, and burden of VMS as well as expert guidance on the latest evidence for new/emerging hormonal and nonhormonal therapies will allow HCPs to provide optimal care to their patients in menopause.

Individualizing Patient Counseling About Management and Treatment Options: Latest Evidence and Guidelines
For patients considering whether to “tough it out” or treat their menopausal symptoms and how this should be accomplished, the decision is personal and often complicated. Encouraging patients to share their symptoms, family and medical history, and preferences supports individualizing their treatment options and plan. HT using conjugated equine estrogens, synthetic conjugated estrogens, micronized 17β-estradiol, or ethinyl estradiol remains an effective medical treatment for VMS, but confusion about the results of the WHI study persists. However, the latest guidelines and evidence regarding the use of HT for treating VMS informs HCPs about the risks and benefits of HT regarding outcomes such as cancer, cardiovascular disease, cognitive impairment, venous thromboembolism, and osteoporosis. Various factors such as age at the start of menopause, time since menopause, and the length of HT affect HT decisions. For many patients, HT is contraindicated or is not acceptable and they express preferences for nonhormonal treatment options.

The North American Menopause Society released updated guidelines in 2023 for the nonhormonal management of menopausal VMS. Of note, the updated guidelines include 2 FDA-approved prescription therapies: paroxetine mesylate (a selective serotonin reuptake inhibitor), approved in 2013, and fezolinetant (a neurokinin 3 receptor antagonist), approved in 2023. In addition, elinzanetant is a neurokinin receptor antagonist in phase III clinical trials that also shows promise in VMS management. These agents offer hope, for patients and HCPs alike, for a pathway toward VMS control that fits their individual needs.

Being up to date on the guidelines and clinical trial results allows HCPs to provide the highest quality of personalized and evidence-based care to their patients experiencing menopausal VMS. For more information on optimizing menopause care, be sure to register and join us live in Boston or via simulcast on Wednesday, April 17, for an exciting symposium exploring the latest data and place in therapy of HT and nonhormonal therapies to manage VMS of menopause. And of course, we will give you ample opportunity to ask us questions. We are looking forward to seeing you there or online! 

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Poll

1.

What are the most common barriers to treating menopause-associated VMS in your patients? (Choose all that apply)

2.

Which of the following nonhormonal therapies would you consider to help patients manage menopause-associated VMS? (Choose all that apply) 

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