- Email: [email protected]
EMAS position statements and clinical guides
Maturitas 77 (2014) 303–304
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Editorial
EMAS position statements and clinical guides
The European Menopause and Andropause Society (EMAS) has produced fifteen position statements and clinical guides published in Maturitas since 2010. The aim is to provide consensus advice on common clinical problems in an easily accessible form for the busy clinician. The scope includes diagnosis, management of women with comorbidities and diet and lifestyle issues including the use of vitamin D. A holistic approach is adopted examining a variety of treatment modalities, not restricted to menopausal hormone therapy (MHT). As people are deferring child bearing and cancer survival is increasing, the issues of fertility preservation and late parenthood are also considered. This editorial summarizes the statements and guides so far. Diagnosis and screening cover bone densitometry screening for osteoporosis and endometrial assessment in peri and postmenopausal women. It discusses population and opportunistic screening. It concludes that while bone densitometry has an important role in screening postmenopausal women for osteoporosis, for higher sensitivity and specificity, there may be a stronger case for screening in later life, depending on the extent to which risk factors add to the value of bone mineral density tests [1]. Endometrial assessment is primarily indicated to diagnose or exclude endometrial cancer and its precursors: endometrial hyperplasia with or without atypia and the intra-epithelial neoplasia [2]. The guide discusses how and when to do so. The how includes ultrasound and hysteroscopy examination and biopsy as well as further assessment with MRI. When is for symptomatic and asymptomatic women, and those with inconclusive investigations and persistent symptoms. Further advice is given for hormone therapy, selective estrogen receptor modulator and aromatase inhibitor users, and those who have had a previous endometrial ablation. Systemic comorbidities covers obesity [3], coronary heart disease (CHD) [4], venous thromboembolism (VTE) [5] and epilepsy [6]. Over 20% of postmenopausal women are obese. It increases the risk of many medical conditions notably type 2 diabetes mellitus, cardiovascular disease, VTE and breast and gynecological cancers [3]. This affects prescribing MHT. Thus the lowest effective estrogen dose should be used, preferably administered transdermally as it is associated with a lower risk of VTE. With regard to progestogens, although no randomized controlled trial data exist, there are observational studies showing that micronized progesterone or dydrogesterone may have a better risk profile with respect to breast cancer risk. Similarly observational data suggest that micronized progesterone or pregnane derivatives may be associated with a lower VTE risk compared to nonpregnane derivatives. Similar recommendations for MHT regimens are made for women with CHD or VTE seeking treatment because of troublesome climacteric 0378-5122/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.maturitas.2014.01.010
symptoms [4,5]. Epilepsy is chronic neurological condition which may advance the age of natural menopause by 3–5 years depending on seizure frequency [6]. Data are limited with regard to use of MHT with regard to seizure frequency and herbal preparations should be avoided because they may interact with anti-epileptic drugs. Gynecological conditions span premature menopause [7], endometriosis[8] and lichen sclerosus [9]. Premature ovarian failure (POF) affects 1% of women under the age of 40 and is therefore a common problem [7]. Untreated it increases the risk of osteoporosis, cardiovascular disease, dementia, cognitive decline and Parkinsonism. The mainstay of treatment is MHT which needs to be continued until the average age of the natural menopause. With regard to endometriosis, the concerns are the effects of estrogen deficiency caused by medical or surgical treatment of the disease and the risk of recurrence induced by MHT [8]. The data regarding MHT regimens are limited but it may be safer to give either continuous combined estrogen–progestogen therapies or tibolone in both hysterectomised and nonhysterectomised women as the risk of recurrence and malignant transformation of residual endometriosis may be reduced. Vulvar lichen sclerosus is a chronic inflammatory condition which causes pruritus and pain and increases the risk of squamous cell carcinoma [9]. First line treatment is an ultra-potent corticosteroid topical cream with surgery reserved for women with malignancy or postinflammatory sequelae. As an increasing holistic approach is given to management of health in midlife and beyond, diet and lifestyle [10] and vitamin D [11] are considered. There is increasing evidence that life-style factors, such as nutrition, physical activity, smoking and alcohol consumption have a profound effect on health [10]. It is concluded that a healthy diet should be maintained through appropriate macroand micronutrients and obesity avoided. Type 2 diabetes mellitus is best prevented or managed by restricting the total amount of carbohydrate and deriving carbohydrate energy from whole-grain cereals, fruits and vegetables. Consuming mono-unsaturated and omega-3 fatty acids is important for the prevention of cardiovascular disease. Vitamin D deficiency and insufficiency are common and may affect up to 70% of European populations [11]. In northern latitudes lack of sunlight leads to deficiency in the winter months. Adequate intake is essential for bone health and recommendations about supplementation are given.Two specific therapeutic options are considered: low dose topical vaginal estrogens [12] and selective estrogen receptor modulators (SERMS) for postmenopausal osteoporosis [13]. Vaginal atrophy is a common chronic condition resulting from estrogen deficiency after the menopause [12].
304
Editorial / Maturitas 77 (2014) 303–304
Low dose vaginal estrogens are effective and there is no need for added progestogen for endometrial protection if they are used in the recommended doses. As there are safety concerns about topical estrogens in postmenopausal women taking adjuvant aromatase inhibitors because of systemic absorption, nonhormonal lubricants and moisturizers should be considered first line. With regard to SERMS both raloxifene and bazedoxifene reduce the risk of vertebral fracture without stimulating the endometrium, unlike tamoxifen [13]. However all SERMS increase the risk of venous thromboembolism and hot flushes. The two latest statements consider the thorny issues of fertility and its deferment [14,15]. It is well known that increasing parental age is associated with infertility and pregnancy complications and may have an impact on long-term health in the offspring [14]. Thus an interdisciplinary approach to counseling parents-to-be of advanced age is recommended. Fertility preservation is considered in both pre-pubertal and post-pubertal men and women in the context of both increasing survival after treatment for cancer and adults who wish to postpone parenthood [15]. It is recommended that if gonadotoxic treatment has to be used, methods of fertility preservation should be discussed, as early as possible. Contributor Margaret Rees is the sole author. Competing interests
References [1] Brincat M, Calleja-Agius J, Erel CT, et al. EMAS position statement: bone densitometry screening for osteoporosis. Maturitas 2011;68:98–110. [2] Dreisler E, Poulsen LG, Antonsen SL, et al. EMAS clinical guide: assessment of the endometrium in peri and postmenopausal women. Maturitas 2013;75: 181–90. [3] Lambrinoudaki I, Brincat M, Erel CT, et al. EMAS position statement: managing obese postmenopausal women. Maturitas 2010;66:323–6. [4] Schenck-Gustafsson K, Brincat M, Erel CT, et al. EMAS position statement: managing the menopause in the context of coronary heart disease. Maturitas 2011;68:94–7. [5] Tremollieres F, Brincat M, Erel CT, et al. EMAS position statement: managing menopausal women with a personal or family history of VTE. Maturitas 2011;69:195–8. [6] Erel CT, Brincat M, Gambacciani M, et al. EMAS position statement: managing the menopause in women with epilepsy. Maturitas 2010;66:327–8. [7] Vujovic S, Brincat M, Erel CT, et al. EMAS position statement: managing women with premature ovarian failure. Maturitas 2010;67:91–3. [8] Moen MH, Rees M, Brincat M, et al. EMAS position statement: managing the menopause in women with a past history of endometriosis. Maturitas 2010;67:94–7. [9] Pérez-López FR, Ceausu I, Depypere H, et al. EMAS clinical guide: vulvar lichen sclerosus in peri and postmenopausal women. Maturitas 2013;74:289–92. [10] Lambrinoudaki I, Ceausu I, Depypere H, et al. EMAS position statement: diet and health in midlife and beyond. Maturitas 2013;74:99–104. [11] Pérez-López FR, Brincat M, Erel CT, et al. EMAS position statement: vitamin D and postmenopausal health. Maturitas 2012;71:83–8. [12] Rees M, Pérez-López FR, Ceasu I, et al. EMAS clinical guide: low-dose vaginal estrogens for postmenopausal vaginal atrophy. Maturitas 2012;73:171–4. [13] Palacios S, Brincat M, Erel CT, et al. EMAS clinical guide: selective estrogen receptor modulators for postmenopausal osteoporosis. Maturitas 2012;71: 194–8. [14] Mintziori G, Lambrinoudaki I, Kolibianakis EM, et al. EMAS position statement: late parenthood. Maturitas 2013;76:200–4. [15] Mintziori G, Lambrinoudaki I, Ceausu I, et al. EMAS position statement: fertility preservation. Maturitas 2014;77:85–9.
Margaret Rees is the president of EMAS. Funding None was sought or secured for this editorial. Provenance and peer review Commissioned, not externally peer reviewed.
Margaret Rees Women’s Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK E-mail addresses: [email protected], [email protected]
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Editorial
EMAS position statements and clinical guides
The European Menopause and Andropause Society (EMAS) has produced fifteen position statements and clinical guides published in Maturitas since 2010. The aim is to provide consensus advice on common clinical problems in an easily accessible form for the busy clinician. The scope includes diagnosis, management of women with comorbidities and diet and lifestyle issues including the use of vitamin D. A holistic approach is adopted examining a variety of treatment modalities, not restricted to menopausal hormone therapy (MHT). As people are deferring child bearing and cancer survival is increasing, the issues of fertility preservation and late parenthood are also considered. This editorial summarizes the statements and guides so far. Diagnosis and screening cover bone densitometry screening for osteoporosis and endometrial assessment in peri and postmenopausal women. It discusses population and opportunistic screening. It concludes that while bone densitometry has an important role in screening postmenopausal women for osteoporosis, for higher sensitivity and specificity, there may be a stronger case for screening in later life, depending on the extent to which risk factors add to the value of bone mineral density tests [1]. Endometrial assessment is primarily indicated to diagnose or exclude endometrial cancer and its precursors: endometrial hyperplasia with or without atypia and the intra-epithelial neoplasia [2]. The guide discusses how and when to do so. The how includes ultrasound and hysteroscopy examination and biopsy as well as further assessment with MRI. When is for symptomatic and asymptomatic women, and those with inconclusive investigations and persistent symptoms. Further advice is given for hormone therapy, selective estrogen receptor modulator and aromatase inhibitor users, and those who have had a previous endometrial ablation. Systemic comorbidities covers obesity [3], coronary heart disease (CHD) [4], venous thromboembolism (VTE) [5] and epilepsy [6]. Over 20% of postmenopausal women are obese. It increases the risk of many medical conditions notably type 2 diabetes mellitus, cardiovascular disease, VTE and breast and gynecological cancers [3]. This affects prescribing MHT. Thus the lowest effective estrogen dose should be used, preferably administered transdermally as it is associated with a lower risk of VTE. With regard to progestogens, although no randomized controlled trial data exist, there are observational studies showing that micronized progesterone or dydrogesterone may have a better risk profile with respect to breast cancer risk. Similarly observational data suggest that micronized progesterone or pregnane derivatives may be associated with a lower VTE risk compared to nonpregnane derivatives. Similar recommendations for MHT regimens are made for women with CHD or VTE seeking treatment because of troublesome climacteric 0378-5122/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.maturitas.2014.01.010
symptoms [4,5]. Epilepsy is chronic neurological condition which may advance the age of natural menopause by 3–5 years depending on seizure frequency [6]. Data are limited with regard to use of MHT with regard to seizure frequency and herbal preparations should be avoided because they may interact with anti-epileptic drugs. Gynecological conditions span premature menopause [7], endometriosis[8] and lichen sclerosus [9]. Premature ovarian failure (POF) affects 1% of women under the age of 40 and is therefore a common problem [7]. Untreated it increases the risk of osteoporosis, cardiovascular disease, dementia, cognitive decline and Parkinsonism. The mainstay of treatment is MHT which needs to be continued until the average age of the natural menopause. With regard to endometriosis, the concerns are the effects of estrogen deficiency caused by medical or surgical treatment of the disease and the risk of recurrence induced by MHT [8]. The data regarding MHT regimens are limited but it may be safer to give either continuous combined estrogen–progestogen therapies or tibolone in both hysterectomised and nonhysterectomised women as the risk of recurrence and malignant transformation of residual endometriosis may be reduced. Vulvar lichen sclerosus is a chronic inflammatory condition which causes pruritus and pain and increases the risk of squamous cell carcinoma [9]. First line treatment is an ultra-potent corticosteroid topical cream with surgery reserved for women with malignancy or postinflammatory sequelae. As an increasing holistic approach is given to management of health in midlife and beyond, diet and lifestyle [10] and vitamin D [11] are considered. There is increasing evidence that life-style factors, such as nutrition, physical activity, smoking and alcohol consumption have a profound effect on health [10]. It is concluded that a healthy diet should be maintained through appropriate macroand micronutrients and obesity avoided. Type 2 diabetes mellitus is best prevented or managed by restricting the total amount of carbohydrate and deriving carbohydrate energy from whole-grain cereals, fruits and vegetables. Consuming mono-unsaturated and omega-3 fatty acids is important for the prevention of cardiovascular disease. Vitamin D deficiency and insufficiency are common and may affect up to 70% of European populations [11]. In northern latitudes lack of sunlight leads to deficiency in the winter months. Adequate intake is essential for bone health and recommendations about supplementation are given.Two specific therapeutic options are considered: low dose topical vaginal estrogens [12] and selective estrogen receptor modulators (SERMS) for postmenopausal osteoporosis [13]. Vaginal atrophy is a common chronic condition resulting from estrogen deficiency after the menopause [12].
304
Editorial / Maturitas 77 (2014) 303–304
Low dose vaginal estrogens are effective and there is no need for added progestogen for endometrial protection if they are used in the recommended doses. As there are safety concerns about topical estrogens in postmenopausal women taking adjuvant aromatase inhibitors because of systemic absorption, nonhormonal lubricants and moisturizers should be considered first line. With regard to SERMS both raloxifene and bazedoxifene reduce the risk of vertebral fracture without stimulating the endometrium, unlike tamoxifen [13]. However all SERMS increase the risk of venous thromboembolism and hot flushes. The two latest statements consider the thorny issues of fertility and its deferment [14,15]. It is well known that increasing parental age is associated with infertility and pregnancy complications and may have an impact on long-term health in the offspring [14]. Thus an interdisciplinary approach to counseling parents-to-be of advanced age is recommended. Fertility preservation is considered in both pre-pubertal and post-pubertal men and women in the context of both increasing survival after treatment for cancer and adults who wish to postpone parenthood [15]. It is recommended that if gonadotoxic treatment has to be used, methods of fertility preservation should be discussed, as early as possible. Contributor Margaret Rees is the sole author. Competing interests
References [1] Brincat M, Calleja-Agius J, Erel CT, et al. EMAS position statement: bone densitometry screening for osteoporosis. Maturitas 2011;68:98–110. [2] Dreisler E, Poulsen LG, Antonsen SL, et al. EMAS clinical guide: assessment of the endometrium in peri and postmenopausal women. Maturitas 2013;75: 181–90. [3] Lambrinoudaki I, Brincat M, Erel CT, et al. EMAS position statement: managing obese postmenopausal women. Maturitas 2010;66:323–6. [4] Schenck-Gustafsson K, Brincat M, Erel CT, et al. EMAS position statement: managing the menopause in the context of coronary heart disease. Maturitas 2011;68:94–7. [5] Tremollieres F, Brincat M, Erel CT, et al. EMAS position statement: managing menopausal women with a personal or family history of VTE. Maturitas 2011;69:195–8. [6] Erel CT, Brincat M, Gambacciani M, et al. EMAS position statement: managing the menopause in women with epilepsy. Maturitas 2010;66:327–8. [7] Vujovic S, Brincat M, Erel CT, et al. EMAS position statement: managing women with premature ovarian failure. Maturitas 2010;67:91–3. [8] Moen MH, Rees M, Brincat M, et al. EMAS position statement: managing the menopause in women with a past history of endometriosis. Maturitas 2010;67:94–7. [9] Pérez-López FR, Ceausu I, Depypere H, et al. EMAS clinical guide: vulvar lichen sclerosus in peri and postmenopausal women. Maturitas 2013;74:289–92. [10] Lambrinoudaki I, Ceausu I, Depypere H, et al. EMAS position statement: diet and health in midlife and beyond. Maturitas 2013;74:99–104. [11] Pérez-López FR, Brincat M, Erel CT, et al. EMAS position statement: vitamin D and postmenopausal health. Maturitas 2012;71:83–8. [12] Rees M, Pérez-López FR, Ceasu I, et al. EMAS clinical guide: low-dose vaginal estrogens for postmenopausal vaginal atrophy. Maturitas 2012;73:171–4. [13] Palacios S, Brincat M, Erel CT, et al. EMAS clinical guide: selective estrogen receptor modulators for postmenopausal osteoporosis. Maturitas 2012;71: 194–8. [14] Mintziori G, Lambrinoudaki I, Kolibianakis EM, et al. EMAS position statement: late parenthood. Maturitas 2013;76:200–4. [15] Mintziori G, Lambrinoudaki I, Ceausu I, et al. EMAS position statement: fertility preservation. Maturitas 2014;77:85–9.
Margaret Rees is the president of EMAS. Funding None was sought or secured for this editorial. Provenance and peer review Commissioned, not externally peer reviewed.
Margaret Rees Women’s Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK E-mail addresses: [email protected], [email protected]