Guidelines for Counseling Women on the Management of Menopause
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Guidelines for Counseling Women on the Management of Menopause
By the Jacobs Institute of Women's Health Expert Panel on Menopause Counseling
Produced in Collaboration with The National Committee for Quality Assurance, The American College of Obstetricians and Gynecologists, and The North American Menopause Society
William C. Andrews, MD, FACOG,
Carol S. Weisman, PhD
Mary Kay Holleran, RN
Cynda Johnson, MD
Elizabeth A. Mort, MD, MPH
Donna Rae Richardson, JD, RN
Cheryl Warner, MD
Nancy Fugate Woods, PhD, RN, FAAN
Advisors to the Panel
Karen Scott Collins, MD
Earl P. Steinberg, MD, MPP
Stanley Zinberg, MD
TABLE OF CONTENTS
These guidelines were developed by a multidisciplinary panel of experts convened by the Jacobs Institute in autumn 1999. The Jacobs Institute would like to thank all the panel members, and in particular, co-chairs William Andrews and Carol Weisman, for synthesizing a complex and evolving body of literature and for their dedication to accuracy and balance. They were aided in this endeavor by various advisors, including Karen Scott Collins, Earl Steinberg, and Stanley Zinberg. The entire process was coordinated and the final report carefully edited by Emily Schifrin.
We would also like to acknowledge Kani Ilangovan, a student at the University of Illinois College of Medicine, for assistance with the literature review, and the following individuals for sharing information and materials with us: Diana Taylor, RN, PhD, UCSF; Nancy Avis, PhD, New England Research Institute; Annette O'Connor, RN, PhD, University of Ottawa; Ellen Gold, PhD, University of California, Davis; and Andrea LaCroix, PhD and Katherine Newton, RN, PhD, Center for Health Studies, Group Health Cooperative of Puget Sound.
These guidelines were developed in collaboration with the National Committee for Quality Assurance, which developed and implements HEDIS® measures of health plan performance, the American College of Obstetricians and Gynecologists, and The North American Menopause Society. Support was provided by The Commonwealth Fund, a New York City-based private independent foundation. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.
These guidelines are intended to assist clinicians (physicians, advanced practice nurses, health educators and others) and health plans in providing comprehensive counseling to women about managing menopause. The guidelines also specifically address the elements of counseling that are assessed in a new measure in the Health Plan Employer Data and Information Set (HEDIS).
In HEDIS 2000, the National Committee for Quality Assurance introduced the Management of Menopause measure. This survey measure, the first in HEDIS's Informed Health Care Choices domain, evaluates the provision of counseling on managing perimenopausal and postmenopausal hormone changes to women age 47 to 55, during the past two years or ever, by their managed care organization.
The measure is scored as a composite of three components: exposure (whether and when counseling occurred); breadth (whether the counseling included information on the risks, benefits, and alternatives to hormone replacement therapy [ERT/HRT]), and personalization (whether the counseling involved consideration of the woman's personal and family medical histories and her own concerns). In order to achieve the maximum score, plans must demonstrate that this level of counseling was provided within the last two years. The measure does not assess the decisions the woman makes.
The HEDIS Management of Menopause measure was designed to determine whether health plans and/or their clinicians have provided at least adequate counseling, not necessarily optimal counseling. We believe that most health plans and clinicians will want to go beyond the minimum. This set of guidelines indicates what may be necessary to fulfill the HEDIS requirements, but it also makes further recommendations about how clinicians and health plans can provide the most complete counseling to perimenopausal and postmenopausal women.
Ongoing clinical research continues to expand our understanding of the effectiveness and safety of existing therapies and preventive strategies for perimenopausal and menopausal women, and new treatments are being introduced as well. These guidelines are based on existing evidence, but clinicians will need to continually update their knowledge in this area, and we include recommendations on how they can do so. The guidelines do not recommend specific treatments.
· Scientific definitions for menopause-related terminology are included in the Glossary. Since many of the issues we address in this document pertain to both perimenopausal and postmenopausal women, and since menopause can only be determined retrospectively, we use the term "menopausal" to refer to women for whom the HEDIS measure is intended. When necessary (e.g., when discussing vaginal dryness, which is more likely to occur after the menopause), we distinguish between perimenopausal and postmenopausal women.
· Managed care organizations wishing to implement the HEDIS Management of Menopause measure must obtain the technical specifications for the measure, which can be ordered from NCQA by calling 1-800-839-6487.
The focus of this document is on counseling women about the hormonal changes that occur at menopause, the effects of these changes, and ways to prevent and treat conditions associated with menopause and aging. For ease of use, it is divided into the following sections:
Counseling Women about Menopause defines counseling and provides suggestions for clinicians and health plans that may help them to optimize menopause counseling.
Providing Personalized Menopause Counseling
Face-to-face contact between a patient and clinician may be what most commonly comes to mind when one thinks of "patient counseling." However, there are many methods of providing information to patients, such as classes or support groups, print materials, audio and videotape decision-making tools, telephone resource lines, and Internet tools.
In the HEDIS Management of Menopause measure, counseling refers to communication of information to assist a woman in making informed decisions about her health. In the context of the measure, counseling is not limited to a face-to-face encounter, but includes all information the patient received from her clinician(s) or health plan. It is likely that one or more face-to-face encounters will be required to assist the woman in personalizing the information she has received.
The HEDIS survey measure is designed to determine whether some type of counseling occurred, and if so, what components were included. Respondents are asked whether they were given any information about menopause by their clinician(s) or health plan. If so, they are asked if they were told about the potential benefits and risks of ERT/HRT and about alternative therapies or approaches to disease prevention and menopausal symptom relief. In addition, the survey asks about personalization of this information, i.e., did the counseling take into account the woman's medical history, family history, values, preferences, and concerns? Respondents are also queried about whether they had a chance to ask all of their questions.
The objectives of counseling include addressing women's questions and concerns, providing patient education, facilitating informed decision making, and enhancing the patient's confidence in the decision made and in her ability to carry it out or modify it over time. A partnership between clinician and patient characterized by mutual respect and trust enhances counseling.
If a therapy is chosen, the patient and clinician should agree on the goals, whether they are short-term (menopause symptom relief), long-term (primary or secondary prevention of diseases associated with aging), or both. The clinician should re-visit decisions about menopause management with the patient at subsequent visits, as new research is published and the woman's health status and preferences may change over time. For instance, a woman who begins taking ERT/HRT to help with the symptoms of menopause will later need to evaluate the risks and benefits of long-term continuation.
Continuing therapy is another key issue in the management of menopause. The woman may experience troublesome side effects from pharmacologic agents, or fail to experience the expected or desired results. If the treatment decision was one made in partnership with her clinician, a woman is more likely to consult with the clinician before changing or discontinuing her treatment plan.
Designing an Approach for Menopause Counseling
Suggestions for Clinicians
· Make an effort to address all of the patient's questions, including those about therapies you would not recommend. Treat the woman's questions respectfully, even if her facts or sources are not ones you endorse.
· Ensure that the scientific information presented to the patient is objective. Achieve balance in presenting options, i.e., be aware of any biases you may have.
· Educate the woman about relevant health conditions (such as heart disease and osteoporosis) so she appreciates how these diseases could affect her quality of life in the future.
· Discuss the known risks and benefits associated with each option, and present in lay terminology information about the strength of the existing evidence and what remains unknown.
· Personalize the discussions based on the woman's health, social history, and family history.
· Consider the patient's preferences, values, and key concerns (e.g., family members' experiences, concern about breast cancer, etc.).
· Tailor the use of materials to the needs and wants of the woman. For example, some patients may want to read key scientific studies while others may prefer concise booklets that briefly summarize relevant information. Consider using high-quality decision-making tools and educational materials and programs to enhance the office visit counseling session.
· Consider with the woman practical issues that she may face if medication will be part of her management plan, such as cost, convenience, and side effects that might affect her desire to continue therapy.
· Ensure that follow-up is routinely done with all patients who start a treatment regimen. The interval for follow-up depends on the patient's needs and concerns.
Suggestions for Managed Care Organizations
· Scientific studies show that physicians' opinions about treatment options remain key determinants in clinical decision-making in general. This suggests that developing tools to assist not only patients, but also physicians, in keeping up-to-date on the facts and issues should improve the quality of clinical decision-making for women entering the menopause. (See the Resources for Clinicians section.)
· Health plans should provide education to clinicians about the collaborative decision-making approach and about the important components of counseling. (See relevant articles, marked with an asterisk, in the Bibliography, particularly Roter et al., 1997 and Strull et al., 1984.)
· Constraints on time for office visits has been cited by primary care doctors as an important barrier to providing comprehensive counseling to patients at the time of menopause. While providing for longer physician office visits might be an ideal approach, offering visits with non-physician clinicians as well as providing educational programs and materials in conjunction with visits may be a more realistic one.
· Given the proliferation of medical information available to consumers in general, it is important for health plans to direct their members to sources of objective information, or to make high-quality educational programs/decision-tools available to their members.
For more information on counseling and shared decision making, see citations in the Bibliography marked with an asterisk.
Women and their clinicians may find the following patient education and decision-making tools helpful.*
Available from the American College of Obstetricians and Gynecologists - Resource Center
Available from The North American Menopause Society
Developed by the Foundation for Informed Medical Decision-Making and available from Health Dialog, Inc.
Available from the Ottawa Health Decision Centre
Available from the American Academy of Family Physicians
Available from the National Osteoporosis Foundation
Available from the National Women's Health Network
Available from Montreal Health Press
Available at bookstores
The New Ourselves, Growing Older by Paula B. Doress-Worters and Diana Laskin Siegal, in Cooperation with the Boston Women's Health Book Collective. 1994.
The Office on Women's Health within the U.S. Department of Health and Human Services has compiled an extensive Menopause Resource Guide on their Web site that includes contact information for relevant federal agencies and organizations, as well as newsletters, magazines, reports and books.
Soon to be available from the Comprehensive Health Enhancement and Support System (CHESS)
Soon to be available from Group Health Cooperative of Puget Sound
· Average age at menopause is 51 (over 90% by age 55)
Note: These topics will be addressed in greater detail in the following section on Managing Menopause.
Clinicians should be prepared to discuss the following topics related to managing common symptoms or reducing the risk of future health conditions. Some of these treatment options are likely to be raised by patients, and clinicians must be familiar with them even if they would not recommend them. Since the strength of the scientific research that demonstrates the efficacy of these treatments varies considerably, clinicians should be able to point out where the scientific evidence is strong and where it is weak or lacking. Information on the potential benefits and risks of all medications should be given. The following list of topics is not intended to recommend any specific treatments.*
Hot Flashes/Day Sweats/Night Sweats
Possible Interventions for Preventing/Treating Diseases of Advancing Age
Coronary Heart Disease (CHD)
Early evidence suggests that ERT/HRT may prove beneficial for the prevention and/or treatment of the following conditions, but more research is needed:
*This document focuses on the symptoms mentioned in the HEDIS Management of Menopause measure, (i.e., vasomotor symptoms and vaginal dryness), which are known to be estrogen-related.
Typical Perimenopause/Menopause Experience
All clinicians caring for women should understand the typical menopause experience.
Menopause occurs with the final menstrual period, which is known with certainty only retrospectively. Women who have not had a spontaneous menstrual period for one year are classified as postmenopausal.1 Perimenopause includes the entire menopausal transition plus one year after the final menstrual period. (See Glossary for additional definitions.)
Age at Menopause
A number of studies in the U.S. have estimated age at menopause. The most recent estimates are from the population-based Massachusetts Women's Health Study. The investigators estimated that women begin the menopausal transition (the time when they first notice changes in their bleeding patterns or begin to experience hot flashes) at about 47 years and have their last menses at about age 51. Women begin the menopausal transition about four years prior to menopause, with a range of two to seven years. Women who smoke tend to experience menopause two years earlier than women who do not smoke, and women who are nulliparous tend to experience menopause earlier than those who are multiparous. By age 55, over 90% of women have experienced menopause.2
Although the Massachusetts Women's Health Study is the largest population-based study of the menopausal transition completed to date, a few factors may limit the generalizability of its results. The majority of women were Caucasian and between 45 and 55 years old at the beginning of the study. As a result, the estimates of age at menopause may be somewhat higher than if women were entered in the study at age 40. Results may not apply across ethnic and racial groups of women not included in the study. The Study of Women and Health in the Nation (SWAN), a multi-site study of the natural history of menopause, is in progress. This study will include representation of African American, Japanese American, Chinese American and Hispanic women as well as Caucasians. As the results of the SWAN study are published, there should be a greater understanding of the natural history of the menopausal transition among several ethnic/racial groups of women in the U.S.
Perimenopausal Changes in the Menstrual Cycle
Recent evidence about the menopausal transition and its endocrine correlates suggests that division of the menopausal transition into discrete stages may enhance our ability to understand its relationship to health outcomes. Based on a population-based study of women in midlife, three menopausal transition stages have been proposed: early, middle and late.1 During the early stages of the transition to menopause, women have regular periods but notice changes in the amount of menstrual flow (often lighter, but it may be heavier and involve flooding or spotting), the number of days of flow (often fewer days of menses, but there may also be more days of menses), or changes in the lengths of their cycles. During the middle transition stage, women's menstrual cycles are irregular (with variability of six days or more between consecutive cycles) but women do not notice skipping of periods. During the late transition stage, women notice skipping of periods, meaning that the interval between their cycles is double or more the length of their usual menstrual cycle. Often their periods are two to three months or more apart.
Symptoms Experienced during the Menopausal Transition
The most prevalent group of menopausal symptoms are the vasomotor symptoms, which include hot flashes, day sweats, and night sweats. Estimates of the percentage of women that experience hot flashes range up to 80%.
Although a number of symptoms have been attributed to the menopause, the prevalence of symptoms other than vasomotor symptoms and vaginal dryness was found to be unrelated to menopause in Canadian women3 and in a Norway cohort.4 Healthy midlife women may experience somatic, neuromuscular, mood fluctuations and other symptoms that are not exclusive to menopausal transition.5,6,7,8 If these symptoms are distressing, they will need to be explored and addressed.
Insomnia is prevalent among midlife women, and seems to be partially related to vasomotor symptoms: women with hot flashes had twice the rate of insomnia as women without hot flashes.2 ERT/HRT appears to improve sleep quality (i.e., increased duration of REM sleep) and reduce the time it takes to fall asleep in menopausal women.9,10 It is important to note that there are many additional causes of insomnia, so attributing insomnia to menopause simply because of a woman's menopausal transition status is not advised.
Depression is a problem reported by menopausal women, but current evidence does not link estrogen levels during the menopausal transition to serious depression.11 While some menopausal women may experience mild and transient depressed mood, serious clinical depression is not caused by menopause. Among U.S. and Canadian women participating in population-based studies, an estimated 23 to 38 percent of women report depressed mood during the perimenopause. Results of the Massachusetts Women's Health Study indicate that the best predictor of depression during the menopausal transition is prior depression.11 Women with a history of depression, including postpartum depression and PMS, could be at higher risk for depression during the menopausal transition than women who have not been depressed earlier in life.12,13 In prospective studies, women reporting depressed mood before menopause, a longer transition to menopause, and more severe menopausal symptoms were more likely to experience depressed mood during the menopausal transition and postmenopause.5
Results of population-based studies support an association between stress exposure and depressed mood.2,14 Given the general association of stress with symptoms, a reasonable explanation for symptoms, particularly dysphoric mood symptoms, could be found in the stressful nature of some women's lives. Longitudinal studies have revealed that women exposed to more stressful events in their lives were those most likely to experience subsequent dysphoric mood and vasomotor symptoms.3,11,13,15,16,17 Women with the most negative attitudes toward menopause and aging reported the most perceived stress and most severe vasomotor and dysphoric mood symptoms during subsequent years of follow-up.12,13,18,19
Longitudinal studies of midlife women demonstrated that those with diagnosed chronic illnesses were also at increased risk of depression.2,3 In another study, midlife women with chronic conditions who rated their health as fair or poor had more perceived stress and dysphoric mood.13
There is no evidence to support a "menopausal syndrome" in population-based studies, suggesting that such observations are largely confined to women seeking care in menopause clinics or consulting clinicians for distressing symptoms. Nonetheless, for some women the menopausal transition may precipitate severe distress. Studies of women attending menopause clinics reveal a high frequency of symptom-related visits. In a California study, 79% of visits by perimenopausal women were for physical symptoms such as vasomotor symptoms and 63% were for depression.20 Women most distressed by menopausal symptoms recalled having premenstrual symptoms prior to perimenopause.4,16,21 This finding suggests that there may be women who are more vulnerable to symptom distress during the transition to menopause.
There is some evidence that menopausal symptoms are a culture-bound phenomenon, with women from cultures not influenced by Western medicine reporting few symptoms or different symptoms.5 A study involving Japanese women revealed that their most frequently reported symptom was shoulder pain, not hot flashes.17 However, it is also possible that the infrequent reporting of hot flashes by Japanese women may be attributable to the high phytoestrogen content in their diets.
Although the pregnancy rate in women 40 years and older is low, approximately 51% of pregnancies in this age group are unintended.22 Women in the perimenopausal stage are potentially able to conceive. Low dose oral contraceptives can provide protection against pregnancy as well as relief from estrogen-related menopausal symptoms.
Strategies for Managing Symptoms
Note: See the following section on Potential Risks of Pharmacologic Agents
Estrogen replacement therapy (ERT) and hormone replacement therapy (HRT) have clearly been shown to be an effective treatment for hot flashes. Taking ERT/HRT on a short-term basis (1-5 years) may be a good strategy for women whose primary concern is hot flashes. Women will need to revisit the issue with their clinicians when it is time to decide whether to taper off ERT/HRT or consider continuing with it for longer-term prevention goals.
Clonidine, bellergal, and low dose oral contraceptives (20 mcg estrogen) have been shown to reduce the incidence of hot flashes. Oral contraceptives have the added benefit of regulating menses and preventing unintended pregnancy in perimenopausal women. Several clinical trials have demonstrated a mild but significant improvement in hot flashes with dietary phytoestrogen supplementation (e.g., soy products), and there is some (inconclusive) evidence that the herb black cohosh may reduce hot flashes and improve mood.24
Strategies for Preventing Diseases of Advancing Age
Strategies for preventing the diseases associated with advancing age can be multi-faceted, and include dietary, exercise, and possibly lifestyle changes as well as pharmacologic interventions. Counseling should consider the broad range of pharmacologic and non-pharmacologic interventions that can address the health considerations under discussion at the time of menopause. Counseling should also include the strength of the supporting scientific evidence for each of the interventions.
Most pharmacologic approaches to managing menopause carry risks as well as benefits. A clinician must have a thorough understanding of a patient's own and her family's histories of cancers, heart and cardiovascular disease, osteoporosis, and other conditions that may influence her inherent risk of developing disease or the degree to which a pharmacologic intervention might increase (or decrease) her risk.26
Coronary Heart Disease
Risk Factors for CHD(28)
Notes: High risk = 2 or more non-cholesterol risk factors.
Possible Interventions for Prevention and/or Treatment of CHD
Note: People with existing CHD, peripheral cardiovascular disease, or diabetes should achieve an LDL(100 mg/dL. Secondary prevention will likely consist of a combination of the American Heart Association's Step II diet, lifestyle/risk factor counseling, exercise, and drug therapy. Adequate folic acid consumption may be beneficial, as it reduces the risk of elevated homocystine level, a cardiovascular risk factor.31
ERT/HRT has been shown to decrease total cholesterol and LDL and also increase HDL. However, ERT/HRT can increase triglyceride levels. (Approximately 25-30 percent of the positive effect of ERT/HRT on CHD is related to lipid effects; the remainder may be related to direct vasodilatation, anti-oxidant effects, and improvement of insulin resistance.)24
· Selective Estrogen Receptor Modulators (SERMS)
Osteoporosis, the most common human bone disease, is characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to bone fragility and an increased risk of fracture. An estimated 10 million Americans have osteoporosis, and another 18 million more have abnormally low bone mass, putting them at risk for painful and debilitating fractures. Postmenopausal Caucasian women are at highest risk, although osteoporosis also affects non-Caucasian women and men. Known risk factors only account for approximately 30% of the incidence of osteoporosis.
Risk Factors for Osteoporosis (34)
*Demonstrated in a large, ongoing prospective U.S. study to be key factors in determining risk of hip fracture (independent of bone density)
Possible Interventions for Prevention and/or Treatment of Osteoporosis
Possible Interventions for Prevention and/or Treatment of Other Diseases
Studies have been consistent in showing a 20-50% reduction in colorectal cancer in current and recent ERT/HRT users. Further study is needed.
Age-Related Macular Degeneration
A large case-controlled study suggested that ERT/HRT may significantly reduce the risk of developing AMD, with current users of ERT/HRT having half the risk of former users and nearly three-quarters less risk than never-users.38
Readers should be aware that a number of professional associations and health agencies have issued consensus statements on the management of menopause, and may wish to consult these statements to supplement the information in this section. These include: The American College of Obstetricians and Gynecologists, the American College of Physicians, the American College of Preventive Medicine, the American Geriatrics Society, The North American Menopause Society, the Society of Obstetricians and Gynaecologists of Canada, and the U.S. Preventive Services Task Force. (All of the preceding are listed in the Bibliography.)
Compared to tumors in never-users, those in ever-users were less likely to have spread to axillary lymph nodes or to more distant sites and more likely to be localized in the breast. There was an increase in the relative risk of spread disease with increased duration of ERT/HRT use.39 Studies of mortality from breast cancer have shown lower mortality for tumors that developed while women were taking estrogen.41
Progestogens do not seem to diminish the risk associated with estrogen use and a recent study has suggested that they may increase breast cancer risk.42
As noted above, some studies have not found an increase in breast cancer risk with ERT/HRT use.43, 44, 45, 46 More research is needed on the relationship between ERT/HRT and breast cancer, and it is hoped that the National Institute of Health's Women's Health Initiative, when completed and analyzed, may provide an answer. Until then, women and their clinicians will need to make the best possible decisions using the existing data. Breast cancer is perhaps the most common fear of women considering ERT/HRT. In order for each woman to make the decision about therapy that is right for her, she and her clinician need to be fully informed on the current state of knowledge on this subject, as well as other risks and benefits of treatment.
Deep Vein Thrombosis
Short-term Side Effects
Unpredictable uterine bleeding occurs in the majority of women on continuous combined HRT during the first 6 to 8 months. Subsequently, bleeding is generally light and stops permanently in most women with endometrial atrophy. Women on cyclical HRT will experience regular, predictable bleeding that may stop after several years or continue.
Note: FDA labeling lists the following as contraindications to the use of both ERT/HRT and birth control pills:
· Known or suspected pregnancy
Upper Gastrointestinal Disturbance
In a randomized clinical trial, risedronate caused no more upper gastrointestinal symptoms than placebo. 52
Deep Vein Thrombosis
Low-Dose Oral Contraceptives
Serious risks, which are rare, include thrombophlebitis, pulmonary embolus, coronary thrombosis, retinal thrombosis, and stroke.
No known risks except with previous allergy.
Frequent side effects include dry mouth, palpitations, drowsiness, dizziness, and hypotension.
The phenobarbital can be addicting, so bellergal should only be used for short periods of time.
Herbal Preparations and Dietary Supplements
Women who choose to use herbal and dietary supplements should know that they are not regulated by the FDA and frequently have not been rigorously tested in human subjects. There are generally no standards for dosage, so the amount of active ingredient may vary from brand to brand. Often, little is known about the efficacy or safety of these substances. For example, herbs or supplements with estrogen-like properties may reduce hot flashes, but it is possible that they may also increase a woman's risk of endometrial cancer.54
Clinicians and health plan quality managers can periodically check the following journals and Web sites for new information on menopause management. The monographs, books, and other resources listed may also be helpful.
Monographs/Professional Education Materials
Available from The North American Menopause Society
Available from the Association of Professors of Obstetrics and Gynecology
Available from Duke University Medical Center
Available from the American Association of Health Plans
Available from the National Osteoporosis Foundation
Available from Lippincott, Williams and Wilkins
Available from the Ottawa Health Decision Centre
Soon to be available from the Comprehensive Health Enhancement and Support System (CHESS)
Soon to be available from Group Health Cooperative of Puget Sound
Health Plan Employer Data and Information Set (HEDIS): HEDIS, a collaborative effort of purchasers, health plans, and consumer organizations under the auspices of the National Committee for Quality Assurance (NCQA), is the most widely used set of health plan performance measures. The measures, which are updated periodically, are designed to enable purchasers and consumers to assess and compare performance among health plans. NCQA also accredits managed care organizations and managed behavioral health care organizations that are able to meet national standards. NCQA's standards and performance measurements for accreditation fall into the following categories: access and service, qualified providers, staying healthy, getting better, and living with illness. HEDIS and accreditation guidelines are available from NCQA (1-800-839-6487; www.ncqa.org).
Menopause*: Natural menopause is the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. Natural menopause is recognized to have occurred after 12 consecutive months of amenorrhea for which there is no other obvious pathological or physiological cause. Menopause occurs with the final menstrual period, which is known with certainty only in retrospect a year or more after the event. An adequate biological marker for the event does not exist.
Perimenopause*: Includes the period immediately prior to the menopause (when the endocrinological, biological, and clinical features of approaching menopause commence) and the first year after menopause.
Climacteric*: The phase in the aging of women marking the transition from the reproductive phase to the non-reproductive state. This phase incorporates the perimenopause by extending for a longer variable period before and after the perimenopause.
Premenopause*: The whole of the reproductive period prior to the menopause.
Postmenopause*: Dates from the final menstrual period, regardless of whether the menopause was induced or spontaneous.
Induced menopause*: The cessation of menstruation which follows either surgical removal of both ovaries (with or without hysterectomy) or iatrogenic ablation of ovarian function (e.g., by chemotherapy or radiation).
Estrogen Replacement Therapy (ERT): The most commonly used oral dose in this country is 0.625 mg of conjugated equine estrogens daily. Other dosages are 1-2 mg of oral estradiol, 0.625-1.25 mg of oral estropipate, and 0.05-0.1 mg transdermal estradiol. ERT is generally prescribed for women who have had their uterus removed.
Hormone Replacement Therapy (HRT): Generally, HRT refers to a combination treatment: estrogen plus progestogen, with the progestogen taken at least 12 days per month. This combination is used in peri- and postmenopausal women who have a uterus, as the progestogen provides protection against the increased risk of endometrial cancer from unopposed estrogen. (Women without a uterus do not need to take progestogen.)
*These definitions were developed by the Council of Affiliated Menopause Societies (CAMS), the international policy organ of the International Menopause Society (IMS), and were approved by the Board of the IMS in October 1999. Wherever possible, CAMS left intact the current accepted definitions in the medical literature; many of these definitions are based on the World Health Organization's.
1 Mitchell E, Woods N, Mariella A. Three Stages of the Menopausal Transition: Observations from the Seattle Midlife Women's Health Study. Menopause (in press).
2 McKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Maturitas 1992;14(2):103-115.
3 Kaufert, PA., Gilbert, P, Tate R. The Manitoba Project: a re-examination of the link between menopause and depression. Maturitas 1992;14(2):143-155.
4 Holte A. Influences of natural menopause on health complaints: a prospective study of healthy Norwegian women. Maturitas 1992;14(2):127-141.
5 Avis, NE, Kaufert, PA, Lock, M, et al. The evolution of menopausal symptoms. Ballieres Clin Endocrinol Metab 1993;7(1):17-32.
6 Mitchell ES, Woods NF. Symptom experiences of midlife women: observations from the Seattle Midlife Women's Health Study. Maturitas 1996;25(1):1-10.
7 Shaver J, Giblin E, Lentz M, et al. Sleep patterns and stability in perimenopausal women. Sleep 1988;11(6):556-561.
8 Taylor D, Lee KA, Beyene Y, et al. More than hot flashes and PMS: midlife women's symptom experience across three ethnic groups. (Submitted.)
9 Schiff I, Regestein Q, Tulchinsky D, et al. Effects of estrogens on sleep and psychological state of hypogonadal women. JAMA 1979;242(22):2405-2407
10 Polo-Kantola P, Erkkola R, Helenius H, et al. When does estrogen replacement therapy improve sleep quality? Am J Obstet Gynecol 1998;178(5):1002-1009.
11 Avis NE, Brambilla D, McKinlay SM, et al. A longitudinal analysis of the association between menopause and depression: results from the Massachusetts Women's Health Study. Ann Epidemiol 1994;4(3):214-20.
12 Woods NF, Mitchell ES. Patterns of depressed mood in midlife women: observations from the Seattle Midlife Women's Health Study. Res Nurs Health 1996;19(2):111-123.
13 Woods NF, Mitchell ES. Pathways to depressed mood for midlife women: observations from the Seattle Midlife Women's Health Study. Res Nurs Health 1997;20(2):119-129.
14 Lock M, Kaufert P, Gilbert P. Cultural construction of the menopausal syndrome: the Japanese case. Maturitas 1988;10(4):317-322.
15 Hunter, M. The south-east England longitudinal study of the climacteric and postmenopause. Maturitas 1992;14(2):117-126.
16 Hunter MS. Predictors of menopausal symptoms: psychosocial aspects. Baillieres Clin Endocrinol Metab 1993;7(1):33-45.
17 Lock, M. Menopause in cultural context. Exp Gerontol 1994;29(3-4):307-317.
18 Avis NE, McKinlay SM. A longitudinal analysis of women's attitudes toward the menopause: results from the Massachusetts Women's Health Study. Maturitas 1991;13(1):65-79
19 Matthews KA, Wing RR, Kuller LH, et al. Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women. J Consult Clin Psychol 1990;58(3):345-351.
20 Anderson E, Hamburger S, Lin JH, et al. Characteristics of menopausal women seeking assistance. Am J Obstet Gynecol 1987;156(2):428-433.
21 Holte A, Mikkelsen A. Psychosocial determinants of climacteric complaints. Maturitas 1991;13(3):205-215.
22 Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998; 30(1):24-29, 46.
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