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Menopause and Osteoporosis Update 2009

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Menopause and Osteoporosis Update 2009 Journal of Obstetrics and Gynaecology Canada The official voice of reproductive health care in Canada Le porte-parole officiel des soins génésiques au Canada Journal d’obstétrique et gynécologie du Canada Volume 31, Number 1 • volume 31, numéro 1 January • janvier 2009 Supplement 1 • supplément 1 Abstract . S1 Preamble . S4 Chapter 1: Towards A Healthier Lifestyle . S5 Chapter 2: Vasomotor Symptoms . S9 Chapter 3: Cardiovascular Disease . S11 Chapter 4: Hormone Therapy and Breast Cancer . S19 Chapter 5: Urogenital Health . S27 Chapter 6: Mood, Memory, and Cognition . S31 Chapter 7: Bone Health . S34 Appendix . S42 Menopause and Osteoporosis Acknowledgements / Disclosures . S46 Update 2009 Publications mailing agreement #40026233 Return undeliverable Canadian copies and change of address notifications to SOGC Subscriptions Services, 780 Echo Dr. Ottawa, Ontario K1S 5R7. #1 -Jan--JOGC cover.indd 1 12/19/2008 3:11:32 PM Editor-in-Chief / Rédacteur en chef Timothy Rowe CPL Editor / Rédactrice PPP Vyta Senikas Translator / Traducteur Martin Pothier Assistant Editor / Rédactrice adjointe Jane Fairbanks Editorial Assistant / Adjointe à la rédaction Daphne Sams Editorial Office / Bureau de la rédaction Journal of Obstetrics and Gynaecology Canada Room D 405A Women's Health Centre Building 4500 Oak Street Vancouver BC V6H 3N1 [email protected] Tel: (604) 875-2424 ext. 5668 Fax: (604) 875-2590 The Journal of Obstetrics and Gynaecology Canada (JOGC) is owned by the Society of Obstetricians and Gynaecologists of Canada (SOGC), published by the Canadian Psychiatric Association (CPA), and printed by Dollco Printing, Ottawa, ON. Le Journal d’obstétrique et gynécologie du Canada (JOGC), qui relève de la Société des obstétriciens et gynécologues du Canada (SOGC), est publié par l’Association des psychiatres du Canada (APC), et imprimé par Dollco Printing, Ottawa (Ontario). Publications Mail Agreement no. 40026233. Return undeliverable Canadian copies and change of address notices to SOGC, JOGC Subscription Service, 780 Echo Dr., Ottawa ON K1S 5R7. USPS #021-912. USPS periodical postage paid at Champlain, NY, and additional locations. Return other undeliverable copies to International Media Services, 100 Walnut St., #3, PO Box 1518, Champlain NY 12919-1518. Numéro de convention poste-publications 40026233. Retourner toutes les copies canadiennes non livrées et les avis de changement d’adresse à la SOGC, Service de l’abonnement au JOGC, 780, promenade Echo, Ottawa (Ontario), K1S 5R7. Numéro USPS 021-912. Frais postaux USPS au tarif des périodiques payés à Champlain (NY) et autres bureaux de poste. Retourner les autres copies non livrées à International Media Services, 100 Walnut St., #3, PO Box 1518, Champlain (NY) 12919-1518. ISSN 1701-2163 SOGC CLINICAL PRACTICE GUIDELINE SOGC CLINICAL PRACTICE GUIDELINENo. 222, January 2009 Menopause and Osteoporosis Update 2009 Values: The quality of the evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. This guideline was reviewed and approved by the Executive and Recommendations for practice were ranked according to the Council of the Society of Obstetricians and Gynaecologists of method described by the Task Force. See Table. Canada. Sponsor: The Society of Obstetricians and Gynaecologists of PRINCIPAL AUTHORS Canada. Robert L. Reid, MD, FRCSC, Kingston ON Jennifer Blake, MD, FRCSC, Toronto ON Summary Statements and Recommendations Beth Abramson, MD, FRCPC, Toronto ON Aliya Khan, MD, FRCPC, Hamilton ON Chapter 1: Towards a Healthier Lifestyle Vyta Senikas, MD, FRCSC, Ottawa ON No recommendations. Michel Fortier, MD, FRCSC, Quebec QC Chapter 2: Vasomotor Symptoms 1. Lifestyle modifications, including reducing core body temperature, regular exercise, weight management, smoking cessation, and Abstract avoidance of known triggers such as hot drinks and alcohol may be recommended to reduce mild vasomotor symptoms. (IC) Objective: To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy 2. Health care providers should offer HT (estrogen alone or EPT) as women as well as in women presenting with vasomotor symptoms the most effective therapy for the medical management of or with urogenital, mood, or memory concerns, and on menopausal symptoms. (IA) considerations related to cardiovascular disease, breast cancer, 3. Progestins alone or low-dose oral contraceptives can be offered as and bone health, including the diagnosis and clinical management alternatives for the relief of menopausal symptoms during the of postmenopausal osteoporosis. menopausal transition. (IA) Outcomes: Lifestyle interventions, prescription medications, and 4. Nonhormonal prescription therapies, including treatment with complementary and alternative therapies are presented according certain antidepressant agents, gabapentin, clonidine, and to their efficacy in the treatment of menopausal symptoms. bellergal, may afford some relief from hot flashes but have their Strategies for identifying and evaluating women at high risk of own side effects. These alternatives can be considered when HT is osteoporosis, along with options for the prevention and treatment contraindicated or not desired. (IB) of osteoporosis, are presented. 5. There is limited evidence of benefit for most complementary and Evidence: MEDLINE was searched up to October 1, 2008, and the alternative approaches to the management of hot flashes. Without Cochrane databases up to issue 1 of 2008 with the use of a good evidence for effectiveness, and in the face of minimal data controlled vocabulary and appropriate key words. on safety, these approaches should be advised with caution. Research-design filters for systematic reviews, randomized and Women should be advised that, until January 2004, most natural controlled clinical trials, and observational studies were applied to health products were introduced into Canada as “food products” all PubMed searches. Results were limited to publication years and did not fall under the regulatory requirements for 2002 to 2008; there were no language restrictions. Additional pharmaceutical products. As such, most have not been rigorously information was sought in BMJ Clinical Evidence, in guidelines tested for the treatment of moderate to severe hot flashes, and collections, and from the Web sites of major obstetric and many lack evidence of efficacy and safety. (IB) gynaecologic associations world wide. The authors critically reviewed the evidence and developed the recommendations 6. Any unexpected vaginal bleeding that occurs after 12 months of according to the methodology and consensus development amenorrhea is considered postmenopausal bleeding and should process of the Journal of Obstetrics and Gynaecology Canada. be investigated. (IA) 7. HT should be offered to women with premature ovarian failure or early menopause (IA), and it can be recommended until the age of Key Words: Menopause, estrogen, vasomotor symptoms, natural menopause (IIIC). urogenital symptoms, mood, memory, cardiovascular disease, breast cancer, osteoporosis, fragility fractures, bone mineral 8. Estrogen therapy can be offered to women who have undergone density, lifestyle, nutrition, exercise, estrogen therapy, surgical menopause for the treatment of endometriosis. (IA) complementary therapies, bisphosphonates, calcitonin, selective estrogen receptor modulators, antiresorptive agents This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC. JANUARY JOGC JANVIER 2009 l S1 Menopause and Osteoporosis Update 2009 Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health Care* Quality of evidence assessmentH Classification of recommendationsI I: Evidence obtained from at least one properly randomized A. There is good evidence to recommend the clinical preventive controlled trial action II-1: Evidence from well-designed controlled trials without B. There is fair evidence to recommend the clinical preventive randomization action II-2: Evidence from well-designed cohort (prospective or C. The existing evidence is conflicting and does not allow to retrospective) or case-control studies, preferably from more make a recommendation for or against use of the clinical than one centre or research group preventive action; however, other factors may influence decision-making II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in D. There is fair evidence to recommend against the clinical uncontrolled experiments (such as the results of treatment preventive action with penicillin in the 1940s) could also be included in this E. There is good evidence to recommend against the clinical category preventive action III: Opinions of respected authorities, based on clinical L. There is insufficient evidence (in quantity or quality) to make experience, descriptive studies, or reports of expert a recommendation; however, other factors may influence committees decision-making *Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W. Canadian Task Force on Preventive Health Care.
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