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FAQs in Menopause Management
Frequently Asked Questions in Screening and Management of Menopausal Symptoms

Released: October 08, 2024

Expiration: October 07, 2025

JoAnn Pinkerton
JoAnn Pinkerton, MD, FACOG, NCMP
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Key Takeaways
  • Primary care providers should proactively screen for menopause symptoms
  • Treatment should still be considered in patients who have undergone partial hysterectomy if they are experiencing menopause symptoms.
  • As patients age, you may consider tapering treatment down, but that therapy should be tailored if symptoms return.

In this commentary, an expert answers important clinical questions covering the management of patients with perimenopause/postmenopausal, including the importance of proactively screening for symptoms, as well as how menopausal hormone therapy (HT) and nonhormonal therapy can be used to help manage vasomotor symptoms (VMS), and discontinuing treatment.

Do you think that primary care providers (PCPs) should be proactively screening for symptoms of menopause? And if women are experiencing symptoms, should PCPs start treatment and monitoring, or do you recommend referring patients to a specialist?

I do think PCPs should proactively screen for symptoms. It is a great time to start having a conversation and educating women as they enter their 40s, even if they are not experiencing symptoms, as lack of awareness could lead to confusion. If a PCP is comfortable and knowledgeable about managing symptoms, they should prescribe medications accordingly. I refer patients if HT is a possibility but they are very high risk, for example patients who have other medical complications that may put them at risk for complications with HRT. However, the vast majority of patients going through a normal menopausal transition and experiencing VMS should be treated as soon as possible. These patients may be unable to sleep, tired, and irritable. They may not be able to think straight or perform well at work. Issues with their partner and/or children can arise.

As the symptoms of perimenopause/postmenopause can be devastating and cause anxiety, treatment is important, and thankfully, there are many options available. For a typical woman in her 50s who is newly menopausal, the risks of HT are small and the benefits are great; therefore, PCPs should not be afraid to prescribe it.

In cases of partial hysterectomy whereby the ovaries remain but the uterus is removed, it is difficult to determine ovarian function by the date of their last period. In these patients, how do PCPs know when treatment should be started?

These women are not going to have periods, but many will continue to experience monthly hormonal changes, often the same symptoms they might have had preceding their period, premenstrual syndrome symptoms for example. For patients who do not have these as premenstrual symptoms as a reference point, the onset of symptoms such as hot flashes and who are in their late 40s to early 50s are likely perimenopausal. Hot flashes can be characterized by warm sensations that begin at about the chest, move upward to the face and are rapid in onset. They may notice palpitations or that their heart is racing as well. PCPs can feel confident treating these as menopausal symptoms.

As patients get older, when do you start thinking about discontinuing treatment? How do you frame the conversation, and how do you begin the discontinuation process?

I do not feel any pressure to discontinue treatment until patients are nearing their late 50s/early 60s, at which point I recommend tapering down. I usually suggest either a lower dose or stopping treatment for a few weeks. If hot flashes resume, then treatment can be tailored. For those in whom hot flashes do not return, it is still important to consider such issues as bone density and vaginal atrophy. Patients may not need medication for hot flashes but perhaps experience painful intercourse and request help. Vaginal estrogen can be used to treat this. Other medications may be needed to treat osteoporosis. If patients already have osteopenia or are at risk for osteoporosis, PCPs may want to keep them on low-dose HT to help with managing bone health.

What do you recommend for patients who struggle with memory loss? Does HT help, because this is something PCPs might encounter often.

Memory can be affected by loss of sleep associated with menopause and hot flashes. Memory may improve if adequate HT relieves hot flashes, and the patient is able to be well rested. Nonhormonal therapy may also be helpful to improve sleep quality, as it should be noted that such symptoms are not entirely attributable to hormones or menopause. Some are a function of aging. Both HT and nonhormonal therapies may make a big difference.

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In your practice, what has been the most helpful treatment option for patients experiencing symptoms of perimenopause/menopause? Get involved in the discussion by answering the polling question and posting a comment below.

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