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 36, Number 9 • volume 36, numéro 9 September • septembre 2014 Supplement 2 • supplément 2 Abstract . S1 Chapter 1: Assessment and Risk Management of Menopausal Women . S6 Chapter 2: Cardiovascular Disease . S16 Chapter 3: Menopausal Hormone Therapy and Breast Cancer . S23 Chapter 4: Vasomotor Symptoms . S31 Chapter 5: Urogenital Health . S35 Chapter 6: Managing Prescription Therapeutic Agents . S42 Chapter 7: Menopause Ongoing Management of Menopausal Women and Those With Special Considerations . S51 Chapter 8: Sexuality and Menopause . S59 Chapter 9: Complementary and Alternative Medicine (CAM) . S74 Publications mailing agreement #40026233. Return undeliverable Canadian copies and change of address notifications to SOGC Subscriptions Services, 780 Echo Dr. Ottawa, Ontario K1S 5R7. 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 BC Women's Hospital 4500 Oak Street Vancouver BC V6H 3N1 [email protected] Tel: (604) 875-2424 ext. 5668 Fax: (604) 875-2590 http://www.jogc.com 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 The Lowe-Martin Group, 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 The Lowe-Martin Group, 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. The cover image was obtained through the: ISSN 1701-2163 Society of Obstetricians and Gynaecologists of Canada (SOGC) SOGC CLINICAL PRACTICE GUIDELINE No. 311, September 2014 (Replaces No. 222, January 2009) Managing Menopause This clinical practice guideline has been prepared by the The literature searches and bibliographic support for this Menopause and Osteoporosis Working Group, reviewed guideline were undertaken by Becky Skidmore, Medical by the Clinical Practice Gynaecology and Family Physician Research Analyst, Society of Obstetricians and Gynaecologists Advisory Committees, and approved by the Executive and of Canada . Council of the Society of Obstetricians and Gynaecologists Acknowledgement: Claudio N . Soares, MD, PhD, Toronto ON of Canada. Disclosure statements have been received from all contributors . PRINCIPAL AUTHORS Robert Reid, MD, Kingston ON Abstract Beth L . Abramson, MD, Toronto ON Jennifer Blake, MD, Toronto ON Objective: To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women Sophie Desindes, MD, Sherbrooke QC as well as in women presenting with vasomotor or urogenital Sylvie Dodin, MD, Quebec QC symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality . Shawna Johnston, MD, Kingston ON Outcomes: Lifestyle interventions, prescription medications, and Timothy Rowe, MB BS, Vancouver BC complementary and alternative therapies are presented according Namrita Sodhi, MD, Toronto ON to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in Penny Wilks, ND, Dundas ON the peri- and postmenopausal years are reviewed . Approaches Wendy Wolfman, MD, Toronto ON to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are MENOPAUSE AND OSTEOPOROSIS WORKING GROUP presented in the companion osteoporosis guideline . Michel Fortier, MD (Co-Chair), Quebec QC Evidence: Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September Robert Reid, MD (Co-Chair), Kingston ON 2012 with the use of appropriate controlled vocabulary (e .g ., Beth L . Abramson, MD, Toronto ON hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e .g ., hormone therapy, Jennifer Blake, MD, Toronto ON perimenopause, heart disease, and sexuality) . Results Sophie Desindes, MD, Sherbrooke QC were restricted to clinical practice guidelines, systematic Sylvie Dodin, MD, Quebec QC reviews, randomized control trials/controlled clinical trials, and observational studies . Results were limited to publication dates Lisa Graves, MD, Toronto ON of 2009 onwards and to material in English or French . Searches Bing Guthrie, MD, Yellowknife NT were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified Aliya Khan, MD, Hamilton ON through searching the websites of health technology assessment Shawna Johnston, MD, Kingston ON and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice Timothy Rowe, MB BS, Vancouver BC guideline collections . Namrita Sodhi, MD, Toronto ON Penny Wilks, ND, Dundas ON Key Words: Menopause, estrogen, vasomotor symptoms, urogenital symptoms, mood, memory, cardiovascular diseases, Wendy Wolfman, MD, Toronto ON breast cancer, lifestyle, nutrition, exercise, estrogen therapy, complementary therapies, progestin, androgen, menopausal hormone therapy, hormones, estrogen, testosterone, menopause, depression, antidepressants, sexuality J Obstet Gynaecol Can 2014;36(9 eSuppl A):S1–S80 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. SEPTEMBER JOGC SEPTEMBRE 2014 l S1 Managing Menopause Values: The quality of the evidence in this document was rated using Recommendations for Health Care Providers the criteria described by the Report of the Canadian Task Force on 1. A waist circumference ≥ 88 cm (35 in) for women is associated Preventive Health Care (Table 1) . with an increased risk of health problems such as diabetes, heart disease, and hypertension and should be part of the initial SUMMARY STATEMENTS AND RECOMMENDATIONS assessment to identify risk . (II-2A) Chapter 1: 2 . Tobacco-use status should be updated for all patients on a regular basis, (I-A) health care providers should clearly advise patients to Assessment and Risk Management quit, (I-C) the willingness of patients to begin treatment to achieve of Menopausal Women abstinence (quitting) should be assessed, (I-C) and every tobacco user who expresses the willingness to begin treatment to quit Recommendations for Patients should be offered assistance . (I-A) 1 . Women aged 51 to 70 should consume 7 servings of vegetables 3 . Blood pressure should be assessed and controlled as women and fruits, 6 of grain products, 3 of milk and alternatives, and 2 of go through menopause . (II-2B) If the systolic blood pressure is meat and alterna tives daily . (III-A) ≥ 140 mmHg and/or the diastolic blood pressure is ≥ 90 mmHg, a specific visit should be scheduled for the assessment of 2 . A diet low in sodium and simple sugars, with substitution of hypertension . (III-A) unsaturated fats for saturated and trans fats, as well as increased consumption of fruits, vegetables, and fibre, is recommended. (I-A) 4. Women ≥ 50 years of age or postmenopausal and those with addi- tional risk factors, such as current cigarette smoking, diabetes, and 3 . Routine vitamin D supplementation and calcium intake for all arterial hypertension, should have lipid-profile screening done. (II-2A) Canadian adults year round is recommended . (I-A) 5 . A cardiovascular risk assessment using the Framingham Risk 4 . Achieving and maintaining a healthy weight throughout life is Score should be completed every 3 to 5 years for women aged recommended . (I-A) 50 to 75 . (II-2A) 5 . Women aged 18 to 64 should accumulate at least 150 minutes of 6 . A history of past pregnancy complications (preeclampsia, moderate to vigorous aerobic physical activity per week in bouts of gestational hypertension, gestational diabetes, placental abruption, 10 minutes or more . (I-A) idiopathic preterm