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VMS Menopause Care
Empowering Primary Care: Addressing Unmet Needs for VMS Care in Menopause

Released: June 18, 2024

Expiration: June 17, 2025

Talia (Tali) Sobel
Talia (Tali) Sobel, MD, MSCP
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Key Takeaways
  • Despite up to 80% of people with menopause experiencing vasomotor symptoms, 70% do not receive treatment.
  • Primary care providers are often the first point of contact for patients seeking relief from vasomotor symptoms and are tasked with providing short- and long-term treatment plans.
  • In addition to hormone therapy, new nonhormonal treatments for vasomotor symptoms are now approved and provide opportunities to further individualize patient care.

Unmet Needs for VMS Treatment
Approximately 50 million women in the United States are at least 51 years old—the average age of menopause—and it is projected that there will be 90 million postmenopausal patients by 2060. Menopause begins 12 months after a patient’s last menstrual period, and perimenopause includes the start of the menopause transition through the 12 months after the final menstrual period. Up to 80% of people with menopause experience vasomotor symptoms (VMS) (hot flashes and/or night sweats), which can last for more than 7 years. In addition, menopausal symptoms include sleep disturbances, brain fog (difficulty concentrating, short-term memory changes), mood changes (depression, anxiety), weight gain, joint pain, vulvovaginal atrophy, pain with sex, low libido, and urinary symptoms. Menopause can occur prematurely in patients due to bilateral oophorectomy, radiation/chemotherapy, medications, or primary ovarian insufficiency.

Primary care providers (PCPs) are often the first point of contact for patients seeking treatment for VMS and are tasked with providing short-term and long-term treatment plans. Unfortunately, studies have shown that medical training programs do not adequately provide learners with foundational knowledge on menopause, limiting their ability to deliver optimal care to patients experiencing VMS. Kling and colleagues’ 2019 survey study of US medical residents found that although family medicine, internal medicine, and OB/GYN residents acknowledged the importance of menopause training, menopause education in medical training is lacking. This leads to significant knowledge gaps surrounding menopause care, which negatively impacts patients in need of treatment.

This lack of confidence in the ability of healthcare professionals (HCPs) to treat VMS translates into real-life challenges for patients. In 2002, after the Women’s Health Initiative estrogen/progestin arm was closed, prescriptions for hormone therapy (HT) dropped by 80% and have not recovered. Although there is an abundance of evidence supporting the use of HT for the treatment of VMS, HT prescribing rates continue to be low, with up to 70% of people with symptoms remaining untreated. A 2020 study by Ng and colleagues reported that increasing education on menopause improved HCP knowledge and confidence in managing patients in menopause. Therefore, education on VMS pathophysiology, clinical manifestations, and treatment is needed for HCPs in primary care so they can provide optimal care to their patients.

Individualizing Patient Care for VMS
Like many other disease states, patient decision-making surrounding treating VMS is often personal and complicated. HT is the most effective treatment for VMS and includes estrogen-only therapy for people who have had a hysterectomy and estrogen plus progestogen therapy in people with an intact uterus. It is important for HCPs to counsel patients regarding benefits and risks of HT using the latest guidelines and evidence. This includes discussing the impact of HT on the risk of cancer, cardiovascular disease, stroke, cognitive impairment, and venous thromboembolism. The timing of HT initiation is important, too. In people without significant risk factors or contraindications, HT should be initiated within 10 years of the final menstrual period and before 60 years of age to mitigate risk. Patients who cannot or choose not to use HT can consider nonhormonal treatments for managing VMS.

The Menopause Society released guidelines in 2023 for the nonhormonal management of VMS, including 2 FDA-approved nonhormonal medications: paroxetine mesylate (a selective serotonin reuptake inhibitor) and the recently approved novel agent fezolinetant (a neurokinin 3 receptor antagonist). Elinzanetant is a dual neurokinin-1,3 receptor antagonist in phase III clinical trials that also shows promise in VMS management. These agents offer new alternative treatments for VMS to help fit patients’ individual needs.

Encouraging patients to discuss their menopause symptoms, family and past medical history, and preferences for treatment allows HCPs to individualize treatment options. Patient-centered communication strategies such as shared decision-making and motivational interviewing can help guide sensitive conversations about VMS. Finally, it is necessary for primary care HCPs to stay up to date on the clinical guidelines and scientific literature to provide the highest quality of personalized and evidence-based care to their patients experiencing VMS.

Your Thoughts?
As a PCP, what are the most common barriers to treating a patient’s menopause-associated VMS in your practice? Get involved by answering the polling question and posting a comment below.

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

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