Diagnosis and Management

Diagnosis

Menopause diagnosis is primarily clinical based on age, menstrual history and symptoms, while hormonal testing only in specific situations.6

Menopause:

For women aged 45 years and older, menopause is diagnosed if there has been no menstruation for more than 12 months, with or without symptoms.6 In women with a uterus, the cessation of periods is the primary clinical marker. For women who have had a hysterectomy, endometrial ablation, or are using progestin IUD, diagnosis relies on symptoms rather than bleeding patterns.

A thorough medical history that documents the frequency, severity, and impact of menopause symptoms, as well as menstrual history provides valuable diagnostic information. Several symptom assessment tools are available for use by patients.

Laboratory testing such as with hormonal measurements with FSH and estradiol may be required for the following situations:6

Women younger than 45 years who become amenorrheic.
Women under 40 with suspected premature ovarian insufficiency (POI). For POI diagnosis, FSH should be elevated on at least two separate occasions about 4 – 6 weeks apart.17 Estradiol level is not completely necessary for POI diagnosis but a low estrogen level with high FSH provides additional support for the diagnosis.17

Other laboratory testing to rule out other causes of amenorrhea if diagnosis is uncertain (i.e. hyperprolactinemia, thyroid, pregnancy).

Perimenopause:

Perimenopause is diagnosed based on patient history with symptoms and changes in menstrual cycles. Women may experience irregular menstrual cycles that may include skipped periods, shorter cycles, or unusually heavy or light bleeding. Menstrual cycles may be irregular which may include changes in frequency (skipped periods or shorter cycles), or unusual changes in flow (heavy or light bleeding). Of note, menopause symptoms can happen even before menstrual cycle changes occur. Hormone levels, including FSH and estradiol, are not reliable during the perimenopause because of fluctuating hormones during this time.

Management of Menopausal Symptoms

Decision making about menopause management include consideration for most bothersome symptoms, degree of severity of symptoms, menopause stage, presence of uterus, comorbidities and need for perimenopausal contraception/bleeding control.18 Patient’s personal preference about treatment should also be considered as should affordability.

Options for management of menopause symptoms include menopausal hormone therapy (MHT), non-hormonal prescription medications, lifestyle modifications and complementary therapy. A brief description for each is below.

Menopausal hormone therapy (MHT): MHT is the most effective treatment for vasomotor symptoms.19 MHT can also help with sleep, mood issues, GSM and prevent bone loss.10, 15, 20 MHT involves the use of estrogen and progestogen therapy (EPT) for individuals with a uterus or estrogen alone (ET) for those without a uterus. Current guidelines recommend that MHT can safely be initiated in women who are less than 60 years of age or less than 10 years since menopause and have no MHT contraindications.19 Estrogen products available in Canada include oral, transdermal gels and patches, and local vaginal estrogen therapy. Vaginal estrogen therapy provides primarily a local effect for GSM symptoms. Progestogen products include oral, transdermal patch (combined with estrogen) and off label use of progestin intrauterine system (levonorgestrel intrauterine system).

Other MHT options which do not require additional progestogen include the use of a tissue selective estrogen complex (TSEC) which combines conjugated estrogen with bazedoxifene (a SERM) and tibolone. Tibolone is converted in the body to three active metabolites with estrogenic, progestogenic and androgenic activities.

Non-hormonal prescription medications: Non-hormonal prescription medications are viable options for women who have contraindications to MHT, experience adverse effects or prefer not to use MHT. Non-hormonal prescription medications include SSRI/SNRI antidepressants, gabapentin, oxybutynin and fezolinetant.19 Most of these agents are used off label in Canada, except for fezolinetant and clonidine which have been approved by Health Canada for the treatment of VMS. According to the 2023 clinical practice guidelines from The Menopause Society, clonidine is not recommended due to insufficient supporting evidence and an unfavorable side effect profile.21 The newest agent, fezolinetant is a NK3-receptor antagonist is the first medication of its class to have been approved in Canada for the treatment of VMS. It is the first of the NK-receptor antagonists to be approved in Canada (see additional details about KNDy neurons under vasomotor symptoms).

Lifestyle measures: Though lifestyle measures have mixed evidence for their benefit, they are practical approaches for VMS symptoms with many other health benefits. Lifestyle measures include cooling techniques, avoiding triggers, exercise, yoga and maintaining a healthy weight.19, 21 Though the evidence is limited, weight loss may be used to help with VMS.21

Complementary Therapies: Complementary therapies with the most evidence to support their use to help with menopause symptoms include cognitive behavioural therapy and clinical hypnosis.21 Phytoestrogen such as soy and acupuncture have mixed evidence for menopause symptoms.19 Many natural health products have limited evidence of their benefit.19

For more detailed information on management options for menopause please refer to the SOGC guidelines or to the following review in CMAJ.22

Options for Genitourinary Syndrome of Menopause:

There are several options for managing GSM. These provide primarily local effect for GSM symptoms:

Lubricants/moisturizers
Vaginal estrogen therapy (vaginal tablets/ovules, vaginal cream, vaginal ring)
Prasterone (intravaginal DHEA ovules)
Ospemifene (oral tablet)

For more detailed information on management options for GSM please refer to the SOGC guidelines or to the following review in CMAJ.

General Comments about Menopause Management:

Patients have the right to make informed decisions about their care. It is important to provide comprehensive information on management options, including their advantages and disadvantages. Decisions can be influenced by perceived benefits, harms, affordability, beliefs, values, and availability. Respecting patient choices is important, ensuring they are empowered to make decisions on the most appropriate option for them.