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CME

Menopause

General Information

Description

  • natural menopause is a physiologic event characterized by loss of ovarian activity and permanent cessation of menses, diagnosed after 12 consecutive months of amenorrhea without a pathological cause1,2,3
  • menopause may also be induced by surgery, chemotherapy, or radiation, with sudden onset in these circumstances3

Also called

  • menopause also called
    • change of life
    • the change
    • postmenopause
  • perimenopause also called
    • the climacteric
    • the menopausal transition
  • hot flashes also called hot flushes

Definitions

  • reproductive stage defined as the time from menarche (first menstrual period) to beginning of perimenopause (when cycles become variable)3
  • perimenopause (the menopausal transition) defined as the beginning of the physiologic changes leading to ovarian failure in the years preceding the final menstrual period1,2
  • menopause defined as cessation of menses, and often used interchangeably with postmenopause, defined as time from last menstrual period to the end of life3
  • early menopause defined as last menstrual period prior to age 40 years3

References

General references used

  1. Goodman NF, Cobin RH, Ginzburg SB, Katz IA, Woode DE. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the diagnosis and treatment of menopause. Endocr Pract. 2011 Nov-Dec;17 Suppl 6:1-25PDF
  2. American College of Obstetricians and Gynacologists (ACOG). Practice Bulletin No. 141: management of menopausal symptoms. Obstet Gynecol. 2014 Jan;123(1):202-16, reaffirmed 2016, correction can be found in Obstet Gynecol 2016 Jan;127(1):166
  3. Nelson HD. Menopause. Lancet. 2008 Mar 1;371(9614):760-70
  4. Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov;22(11):1155-74
  5. Stuenkel CA, Davis SR, Gompel A, Lumsden MA, Murad MH, Pinkerton JV, Santen RJ. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015 Oct 7;:jc20152236

Recommendation grading systems used

  • American Association of Clinical Endocrinologists (AACE) guideline grading system
    • grades of recommendation
      • Grade A - best evidence level 1, or best evidence level 2 but adjusted upwards for positive subjective factors
      • Grade B - best evidence level 2, or best evidence level 1 adjusted downwards for negative subjective factors, or best evidence level 3 adjusted upwards for positive subjective factors
      • Grade C - best evidence level 3, or best evidence level 2 adjusted downwards for negative subjective factors, or best evidence level 4 adjusted upwards for positive subjective factors
      • Grade D - best evidence level 4, or best evidence level 3 adjusted downwards for negative subjective factors, or < two-thirds consensus (regardless of evidence level)
    • levels of evidence
      • Level 1 - randomized trials or meta-analysis of randomized trials
      • Level 2 - nonrandomized controlled trial, prospective cohort study, retrospective case-control study, or meta-analysis of these types of studies
      • Level 3 - cross-sectional study, surveillance study, consecutive case series, or single case reports
      • Level 4 - no evidence (theory, opinion, consensus, review, or preclinical study)
  • American College of Obstetricians and Gynecologists (ACOG) levels of recommendation
    • Level A - recommendations based on good and consistent scientific evidence
    • Level B - recommendations based on limited or inconsistent scientific evidence
    • Level C - recommendations based primarily on consensus and expert opinion
    • Reference - ACOG Practice Bulletin 141 on management of menopausal symptoms (24463691Obstet Gynecol 2014 Jan;123(1):202, reaffirmed 2016)
  • Endocrine Society uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system
    • strength of recommendation
      • Strong recommendation - guideline panel members have high confidence that desirable effects of recommendation outweigh undesirable effects (or vice versa)
      • Weak recommendation - guideline panel members conclude with less confidence that desirable effects of recommendation probably outweigh undesirable effects, or benefits and harms are finely balanced, or appreciable uncertainty
    • quality of evidence
      • High-quality evidence - consistent evidence from well-performed randomized controlled trials, or exceptionally strong evidence from unbiased observational studies
      • Moderate-quality evidence - randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise evidence), or unusually strong evidence from unbiased observational studies
      • Low-quality evidence - ≥ 1 critical outcome from observational studies, randomized controlled trials with serious flaws, or indirect evidence
      • Very low-quality evidence - ≥ 1 of the critical outcomes from unsystematic clinical observations or very indirect evidence
  • North American Menopause Society (NAMS) levels of evidence
    • levels of evidence
      • Level I - high quality randomized trials, systematic reviews of level I studies
      • Level II - lesser quality randomized controlled trials, systematic reviews of level II studies or level I studies with inconsistent results
      • Level III - uncontrolled trials, case-controlled studies, systematic reviews of level III studies
      • Level IV - case series, case-control studies
      • Level V - expert opinion
    • Reference - NAMS position statement on nonhormonal management of menopause associated vasomotor symptoms (26382310Menopause 2015 Nov;22(11):1155)

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
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    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed Team-initiated groups:
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      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
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DynaMed Editorial Process

  • DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
  • All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated.
  • DynaMed content includes Practice-Changing Updates, with support from our partners, McMaster University and F1000.

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
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    Recommendations Editors provide explicit review of Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114698, Menopause; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T114698. Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

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