Menopause: The Journal of The North American Menopause Society

Vol. 22, No. 3, pp. 000/000

DOI: 10.1097/gme.0000000000000373
* 2014 by The North American Menopause Society

EDITORIAL
Algorithm and mobile app for menopausal symptom management and
hormonal/non-hormonal therapy decision making: a clinical
decision-support tool from The North American Menopause Society

OVERVIEW Women below age 45 or those who are not clearly menopausal,
The Menopause Decision-Support Algorithm (Fig. 1) and as well as women who have had endometrial ablation, progestin-
companion iPhone/iPad app, developed in collaboration releasing intrauterine device/system, or hysterectomy without
with The North American Menopause Society (NAMS), are removal of ovaries, may need additional clinical evaluation
designed to help clinicians decide which patients are can- before applying this algorithm (evaluation may include hCG,
didates for pharmacologic treatment of menopausal symp- FSH, TSH, prolactin, and other tests).3 The algorithm encourages
toms, understand what the treatment options are, and all patients to try lifestyle modifications for at least 3 months
gain experience deciding among the options. Menopausal before beginning HT or other pharmacologic therapies. For in-
symptoms vary dramatically among women.1,2 Some women formation on lifestyle modifications, cognitive behavioral thera-
are good candidates for hormonal treatments and others, due py, and/or alternative remedies, clinicians may want to print out
to their personal preferences or risk factor profiles, are not the materials for the patient at the below link (or send the link by
appropriate candidates and should consider non-hormonal op- email via the app): http://www.menopause.org/docs/for-women/
tions. One of the most complex health care decisions facing mnflashes.pdf. Women at high risk of osteoporotic fracture and
women in mid-life is whether to use prescription medications unable to tolerate standard preventive medications may also be
for menopausal symptom management, and the array of phar- candidates for HT (NAMS Hormone Therapy Position Statement:
macologic options has expanded markedly in recent years.2,3 http://www.menopause.org/docs/default-document-library/
This new app, which can be downloaded free of charge on a psht12.pdf ?sfvrsn=2).2 The algorithm also addresses consider-
mobile phone or tablet device, helps clinicians and patients ations relevant to decisions about duration of treatment, including
work together to Bpersonalize[ treatment decisions, based on balancing risks of breast cancer, cardiovascular disease, and
risk stratification4<9 and the patient_s personal preferences. The osteoporosis.1<3 Each step of the algorithm should be reassessed
mobile app has two modes, one for clinicians and a com- at least once every 12 months or if health status changes.
panion mode for patients, to facilitate shared decision making
and patient-centered care. BACKGROUND
The algorithm and mobile app address options for Bmoderate Women have an increasing number of options, both hormonal
to severe[ hot flashes and/or night sweats (defined as both- and non-hormonal, for the management of menopausal symp-
ersome enough to interfere with daily activities, impair quality toms.1<3 A major deterrent to treatment, however, is the com-
of life, and/or interrupt sleep), as well as genitourinary symp- plexity of the decision-making process and the lack of information
toms (including vaginal dryness or pain with intercourse or about available options. This new algorithm and mobile app
other sexual activities). Convenient links provide information for menopausal symptom management incorporate state-of-
about treatment options, formulations and doses, and contrain- the-science evidence and research to clarify and streamline the
dications to therapy. The app calculates an atherosclerotic car- decision-making process for both patients and clinicians.
diovascular disease (CVD) risk score for each patient,10 which Menopausal HT continues to have an important clinical
is relevant to the decision regarding initiation of systemic role in the management of vasomotor and other menopausal
menopausal hormone therapy (HT). Women at high risk of, or symptoms, but it has complex biological effects. The rational
with significant concern about, breast cancer should be in- use of HT requires balancing the potential benefits and risks of
formed about availability of non hormonal therapies. Once the treatment. Although findings from the Women_s Health Ini-
clinician becomes familiar with the algorithm, personalized tiative (WHI) and other randomized clinical trials have helped
decision-making for most patients will require only 2-3 minutes, to clarify the benefits and risks of HT and provided insights to
and the app provides a summary at the end that can be printed improve decision making,4<7 current options include lower
out or directly emailed to the patient. The tool can be used doses and transdermal formulations that may further minimize
for women with menopausal symptoms who are ages risks. Available research suggests that risk stratification based
Q45 years old. The algorithm can also be used for women on clinical characteristics of the patient has utility in identi-
who have had removal of both ovaries, regardless of age. fying those for whom benefits of HT are likely to outweigh the

Menopause, Vol. 22, No. 3, 2015 1

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 EDITORIAL

FIG. 1. Algorithm for menopausal symptom management and hormonal/non-hormonal therapy decision making. Algorithm footnotes appear at the end
of the article.

FIG. 2. WHI hormone therapy trials: absolute risks (cases per 10,000 person-years) for outcomes in the intervention phases of the estrogen-progestin
and estrogen-alone trials, by age group. Data are from reference 4.

2 Menopause, Vol. 22, No. 3, 2015 * 2014 The North American Menopause Society

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 EDITORIAL

risks.4<9 Age and time since menopause are strong predic- NAMS recommend that treatment be limited to women at high
tors of health outcomes on HT, and the absolute risks of ad- risk of osteoporotic fracture who cannot tolerate alternate os-
verse events are much lower in younger than older women teoporosis therapies.2
(see Fig. 2).4 Differences by age have been particularly appar-
ent for estrogen alone among women with hysterectomy.4,5 In CONCLUSIONS
addition, women at higher baseline cardiovascular risk, due to Risk stratification can be used to identify appropriate can-
dyslipidemia, metabolic syndrome, or other cardiometabolic didates for pharmacologic treatment of menopausal symptoms
risk factors, have greater risk of adverse vascular outcomes and to facilitate a safer and more personalized approach to
on HT than women at lower risk.2<7 These findings, based on clinical decision making. Recent research has advanced our
proximity to menopause, underlying cardiovascular risk, and understanding of the benefits and risks of available treatment
other personal risk factors, have been incorporated into the options and enhanced the ability of both clinicians and pa-
decision-making process used in this algorithm. Women who tients to make informed choices about treatment.
are not candidates for, or do not choose to take, HT can be
evaluated for non-hormonal treatments. The use of risk strat-
Footnotes to Algorithm and Supplemental Tables:
ification and personalized risk assessment offers promise for
improved safety and a more favorable benefit:risk profile for Abbreviations:
both hormonal and non-hormonal treatments. HT = menopausal hormone therapy; FDA= Food and Drug
Administration; NAMS=North American Menopause Society;
CHD=coronary heart disease; TIA=transient ischemic attack;
DECISION-MAKING PROCESS ASCVD= atherosclerotic cardiovascular disease; CVD=cardiovas-
AND TREATMENT OPTIONS cular disease; ACC/AHA= American College of Cardiology/
The key elements of the algorithm (Fig. 1) include assess- American Heart Association; ET=estrogen therapy; EPT=
ment of whether the patient has moderate to severe vasomotor estrogen+progestogen therapy; CE=conjugated estrogens;
symptoms (the primary indication for initiating systemic HT); SSRI=selective serotonin reuptake inhibitors; SNRI= serotonin/
eliciting the patient_s personal preference regarding treat- norepinephrine reuptake inhibitors; hCG=human chorionic
ment; evaluating the patient for the presence of any contrain- gonadotropin; FSH=follicle stimulating hormone; TSH=thyroid
dications to systemic HT, as well as the patient_s time since stimulating hormone; PRL=prolactin.
menopause onset and baseline risks of CVD and breast can- a
This algorithm applies to women with menopausal symp-
cer; reviewing the benefits and risks of treatment with the toms who are Q45 years of age. It can also be used for women
patient (giving more emphasis to absolute than to relative who have had removal of both ovaries, regardless of age.
measures of effect) (Fig. 2); and, if HT is initiated, regularly Women below age 45 or those with uncertain menopausal
reviewing the patient_s need for continued treatment. If hor- status may need additional clinical evaluation before apply-
monal treatment is chosen, lower doses may be effective for ing this algorithm (evaluation may include hCG, FSH, TSH,
many women, and the transdermal route may be preferable to prolactin, and other tests).3 BModerate-to-severe hot flashes
oral for patients with metabolic syndrome or other significant and/or night sweats[ refer to bothersome symptoms that in-
CVD risk factors. In appropriate patients, a tissue-selective terfere with daily activities, impair quality of life, and/or in-
estrogen complex, such as conjugated estrogens combined terrupt sleep. Patients should try lifestyle modifications for at
with bazedoxifene (a selective estrogen receptor modulator) least 3 months before using this algorithm (TAP HERE to see
may be an option. A similar process is followed for non- or print out lifestyle modification guidelines for the patient [or
hormonal treatments in women who are not candidates for, or send the link by email via the app]: http://www.menopause.org/
who choose not to take, hormonal therapy. Paroxetine 7.5 mg/d docs/for-women/mnflashes.pdf). For any medications prescribed,
is an FDA-approved non-hormonal medication for vasomotor clinicians should check product labeling for a comprehensive
symptoms; a wide range of other selective serotonin reuptake listing of contraindications and cautions.
inhibitors or serotonin/norepinephrine reuptake inhibitors, as Women at high risk of osteoporotic fracture but unable to
well as gabapentin, pregabalin, and clonidine, can be consid- tolerate standard preventive medications also may be reason-
ered. For patients who do not have moderate or severe hot able candidates for systemic HT even if they do not have
flashes but have significant genitourinary symptoms (vaginal moderate to severe vasomotor symptoms (TAP HERE to
dryness or pain with intercourse/sexual activities) without see the NAMS HT Position Statement: http://www.menopause.org/
docs/default-document-library/psht12.pdf ?sfvrsn=2).
adequate response to vaginal lubricants and/or moisturizers,
b
low-dose vaginal estrogen is an option. Ospemifene can also Women who have vaginal dryness alone, without moder-
be considered for women without contraindications and who ate to severe vasomotor symptoms, may be candidates for
prefer a non-estrogen oral treatment. Clinicians should check low-dose vaginal estrogen or other treatments. TAP HERE to
product labeling for a comprehensive listing of contraindica- see Table 1 for vaginal estrogen options. Contraindications for
tions and cautions for any medications prescribed. vaginal estrogen include unexplained vaginal bleeding and
Whether or not to initiate systemic HT to prevent osteo- known or suspected breast cancer or other estrogen-dependent
porosis is controversial, but if done, current guidelines from neoplasia. Ospemifene may be an option for women who

Menopause, Vol. 22, No. 3, 2015 3

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 EDITORIAL

prefer a non-estrogen oral treatment. Contraindications for lesterol, HDL cholesterol: 10-Year atherosclerotic CVD
ospemifene include all of those for vaginal estrogen (above), (ASCVD) Risk Score is calculated using the pooled
cohorts equation: ____
as well as past or current venous or arterial thromboembolic
disease. TAP HERE to see other contraindications and cau- Enter number of years since last menstrual period: ___
tions. Women should be evaluated on an ongoing basis for ___Lowf (G5%) 10-Year CVD Risk and less than
genitourinary symptoms, irrespective of other treatments. 10 years since menopause: Patient appears to be a
c candidate for either oral or transdermal therapy. Women
Is the patient interested in considering HT and free of the with hysterectomy can take estrogen-alone therapy (see
following contraindications? TAP HERE to see contraindica- footnote d and TAP HERE for options and dosages).
tions/cautions: unexplained vaginal bleeding; liver dysfunc- Women with an intact uterus on HT should take com-
tion or disease; active or history of deep venous thrombosis bination estrogen plus progestogen (EPT) (TAP HERE
for options and dosages). FDA-approved bioidentical
or pulmonary embolism; known blood clotting disorder or
options (TAP HERE) and pros/cons of oral vs transdermal
thrombophilia; untreated hypertension; history of breast, en- estrogen (TAP HERE) are summarized. Go to footnotes
dometrial cancer, or other estrogen-dependent tumor; known k and l regarding duration of treatment. CE/bazedoxifene
hypersensitivity to HT, or history of CHD, stroke, or TIA. (a 3rd generation selective estrogen receptor modulator) is
Women with one or more 1st degree relatives with breast an additional FDA-approved option for women with an
intact uterus (dosing: CE 0.45 mg and Bazedoxifene
cancer (BC) or otherwise at increased risk of BC (see Breast
20 mg daily) (TAP HERE).
Cancer Risk Score at http://www.cancer.gov/bcrisktool/) may
want to consider non-hormonal therapy. For other contrain- ___Moderateg (5-10%) 10-Year CVD Risk and
dications, including high triglycerides (9400 mg/dL [4.5 less than 10 years since menopause: Patient should
mmol/L]) or gallbladder disease, oral estrogen should be avoid oral estrogen, but transdermal estrogen may be
avoided but transdermal estrogen may be an option. Trans- an option because it has a less adverse effect on clotting
factors, triglyceride levels, and inflammation factors than
dermal estrogen may also be less likely to reduce libido than oral estrogen (TAP HERE to see transdermal options and
oral estrogen. Women taking thyroid medication may need dosages). TAP HERE to see pros/cons of oral vs trans-
dose adjustments. dermal estrogen. TAP HERE to see FDA-approved bio-
d identical options. Go to footnote k and l regarding duration
Women with hysterectomy are candidates for estrogen- of treatment.
alone therapy (ET; TAP HERE to see Tables 2-4 for oral and
transdermal ET options). Women with an intact uterus should g
Women with obesity, diabetes, or metabolic syndrome,
take combination estrogen plus progestogen (EPT; TAP if otherwise considered candidates for HT, may do better
HERE to see Tables 5-8 for EPT options). FDA-approved with transdermal than oral estrogen (TAP HERE to see
bioidentical ET and EPT options are shown in Table 9 (TAP definition of MetS). Metabolic syndrome is defined as the
presence of 3 or more of the following criteria in women:
HERE) and pros and cons of different routes of administration 1) abdominal obesity (waist circumference 935 in [88 cm]);
of HT are shown in Table 10 (TAP HERE). CE/bazedoxifene 2) triglycerides Q150 mg/dL (1.69 mmol/L); 3) high den-
(CE with a 3rd generation selective estrogen receptor modu- sity lipoprotein cholesterol G50 mg/dL (1.3 mmol/L);
lator) is an additional FDA-approved option for women with 4) blood pressure Q130/Q85 mmHg; and 5) fasting glu-
an intact uterus, especially those with concerns about breast cose Q110 mg/dL (6.1 mmol/L) (Adult Treatment Panel III
National Cholesterol Education Program 2010).
tenderness, breast density, or uterine bleeding (TAP HERE);
the contraindications are similar to those for systemic HT
___Highh (910%) 10-Year CVD Risk: Patient
(and/or hypersensitivity to its ingredients). Costs of products
should avoid initiation of systemic hormone therapy.
have a wide range.
Go to footnote i for non-hormonal treatment options.
e
Reassess each step at least once every 6-12 months (as- If the patient has genitourinary symptoms, she may
suming patient’s continued preference for HT) or if patient_s be a candidate for low-dose vaginal estrogen or other
health status changes. Begin with lower doses and, if inade- treatments (go to footnote b).
quate symptom relief within 3-6 months, adjust dose or change
to different treatment. For duration of treatment decisions, see h
Women 910 years past menopause also are gener-
NAMS HT Position Statement: http://www.menopause.org/ ally not good candidates for starting (first use of) sys-
docs/default-document-library/psht12.pdf?sfvrsn=2 and Kau- temic HT (go to footnote b and i). However, decisions
nitz AM. Menopause: June 2014 - Volume 21 - Issue 6 - p 679- about starting or continuing systemic HT beyond age 60
681. Also see footnotes k and l. or more than a decade past menopause (or restarting HT in
f,g,
and hTen-year risk of CVD, based on the ACC/AHA prior users) require individualized decision making and
ASCVD Risk Estimator http://www.imedicalapps.com/2014/ consideration/discussion of the benefit:risk balance (see
04/ascvd-risk-estimator-app/ footnote k and l).
Source: Goff DC, et al, Circ 2013 (reference 10)
i
Enter information on age, smoking, hypertension diag- TAP HERE to see contraindications to SSRIs/SNRIs:
nosis, systolic blood pressure level, diabetes, total cho- hypersensitivity or adverse drug reaction on these medications,

4 Menopause, Vol. 22, No. 3, 2015 * 2014 The North American Menopause Society

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 EDITORIAL

neuroleptic malignant syndrome, serotonin syndrome, and NAMS generally recommends treating for the duration of
concurrent use of MAO inhibitors. SSRIs/SNRIs should be time consistent with treatment goals but avoiding durations
used with caution in patients with bipolar disease, un- longer than 7 years for estrogen-alone and 5 years for EPT
controlled seizures, hepatic or renal insufficiency, uncontrolled (NAMS HT Position Statement: http://www.menopause.org/
hyponatremia, concurrent use of other SSRIs/SNRIs or, poorly docs/default-document-library/psht12.pdf ?sfvrsn=2).
controlled hypertension. May increase suicidal thoughts within However, extended duration treatment may be appropriate in
the first few months of treatment, although observed primarily selected patients, such as women at low risk of breast cancer
in youth and young adults. Preliminary evidence suggests a and CVD but at elevated risk of fracture, or patients at low
possible increase in risk of bone fractures. TAP HERE for risk who have tried to discontinue treatment but have return
Paroxetine dosage and other information: Paroxetine 7.5 mg/d of significant symptoms (see below for further discussion:
(Brisdelle, paroxetine mesylate) is the only SSRI/SNRI http://www.menopause.org/docs/default-source/2013/nams-
currently approved by the FDA for treatment of moderate practice-pearl-extended-ht-duration.pdf)
to severe vasomotor symptoms. Paroxetine and other po-
tent hepatic isoenzyme CYP2D6 inhibitors (e.g., fluoxetine, Algorithm is adapted from: Manson JE, Bassuk SS.The
duloxetine) should be used with caution in women on ta- menopause transition and postmenopausal hormone therapy.
moxifen due to potential reduction in effectiveness of In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL,
tamoxifen. TAP HERE for information on other SSRIs/ Loscalzo J, eds. Harrison’s principles of internal medicine.
SNRIs (off-label use): venlafaxine 75-150 mg/d; escitalopram McGraw Hill: New York 2011; NAMS Hormone Therapy
10-20 mg/d; citalopram 10-30 mg/day; desvenlafaxine 50 mg/d; Position Statement 2012: http://www.menopause.org/docs/
paroxetine hydrochloride 10-20 mg/day; paroxetine CR default-document-library/psht12.pdf?sfvrsn=2); Menopause
12.5-25 mg/day; others (similar contraindications but check Practice: A Clinician_s Guide, 5th edition, NAMS, 2014, and
product labeling). Dosages may need to be adjusted. For severe NAMS website listing of available therapies (http://www.
and resistant symptoms, other less well-established treat- menopause.org/docs/default-source/2014/nams-ht-tables.pdf).
ments, including stellate ganglion blockade, may be options.
j
Resources and Tables Included in the App:
TAP HERE for contraindications to, and dosing of,
Summary of lifestyle modifications that can be tried for
gabapentin, pregabalin and clonidine (off-label use): Gab-
at least 3 months before considering pharmacologic therapy
apentin and pregabalin are contraindicated in patients who
for vasomotor symptoms: NAMS_ MenoNotes on hot flashes
have demonstrated hypersensitivity to the drugs or their
(http://www.menopause.org/docs/for-women/mnflashes.pdf).
ingredients. Caution: anticonvulsants may increase sui-
cidal thoughts and behaviors and cause drowsiness, dizzi- Clinician may want to print this out for the patient (or email it
via the app) as a handout.
ness, and impair balance and coordination. Gabapentin and
NAMS Hormone Therapy Position Statement, 2012: avail-
pregabalin should be dose adjusted in patients with renal
able at: http://www.menopause.org/docs/default-document-
insufficiency. Pregabalin may impair memory and con-
library/psht12.pdf?sfvrsn=2).
centration. Clonidine is contraindicated in patients with
demonstrated hypersensitivity or low blood pressure and PersonalizedEstimation of the 10-Year Atherosclerotic
may cause lightheadedness, hypotension, headache and Cardiovascular Disease Risk Score from the American Col-
constipation; sudden cessation of treatment can be asso- lege of Cardiology/American Heart Association (ACC/AHA
ciated with significant rise in blood pressure. Dosing: ASCVD Risk Estimator) http://www.imedicalapps.com/2014/
gabapentin 900-2400 mg/d (dose divided three times per day); 04/ascvd-risk-estimator-app/
pregabalin 150-300 mg/d (dose divided twice per day); Source: Goff DC, et al, Circulation 2013 (reference 10 above)
clonidine 100 mcg/day. (Dosages may need to be adjusted).
Figure displaying absolute risks of chronic disease out-
k
comes by age group, Women_s Health Initiative Hormone
and lTAP HERE to see information on duration of ET Therapy Trials: data from Manson JE, et al. JAMA 2013;
in a patient with hysterectomy and HERE to see informa- 310:1353-1368 (reference 4 above).
tion on duration of EPT in a patient with an intact uterus.
Decisions about duration of treatment should be individu- NAMS Practice Pearl on Extended Duration Use of Hor-
alized and will depend on a number of factors, including mone Therapy: Kaunitz A. (available online at: http://www.
patient preference for continuing treatment, persistence menopause.org/docs/default-source/2013/nams-practice-pearl-
of moderate-to-severe menopausal symptoms, and the extended-ht-duration.pdf)
patient_s underlying risk of breast cancer, CVD, osteopo-
Several tables adapted from Menopause Practice: A
rotic fracture, and other conditions. Several other tools,
Clinician_s Guide, 5th edition, NAMS, 2014*, including:
including the Gail Score Estimator for Breast Cancer Risk
(http://www.cancer.gov/bcrisktool/) and the Fracture Risk Table 1. Vaginal Estrogen Therapy Products for Postmeno-
Assessment Tool (FRAX; at http://www.shef.ac.uk/FRAX/ pausal Use in the United States and Canada (de-
tool.aspx?country=9), may be helpful for these assessments. tailed listing of products, composition, and dosages)

Menopause, Vol. 22, No. 3, 2015 5

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 EDITORIAL

Table 2. Oral Estrogen Therapy Products for Postmenopausal JoAnn E. Manson, MD, DrPH, NCMP1
Use in the United States and Canada (detailed listing Jeffrey M. Ames, BS, MEng2
of products, composition, and dosages [categories of Marla Shapiro, MD, NCMP3
Margery L.S. Gass, MD, NCMP4
low, moderate, and high]) Jan L. Shifren, MD, NCMP1
Table 3. Transdermal Estrogen Therapy Products for Post- Cynthia A. Stuenkel, MD, NCMP5
menopausal Use in the United States and Canada JoAnn V. Pinkerton, MD, NCMP6
(patches, gels, emulsions, and sprays: detailed listing Andrew M. Kaunitz, MD, NCMP7
of products, composition, and dosages [categories Diane T. Pace, PhD, FNP-BC, NCMP8
Risa Kagan, MD, NCMP9
of low, moderate, and high]) Peter F. Schnatz, DO, NCMP10
Table 4. Approximate Equivalent Estrogen Doses for Postmen- Sheryl A. Kingsberg, PhD4
opausal Use (oral and transdermal formulations) James H. Liu, MD4
Table 5. Combination Estrogen-Progestogen Therapy Prod- Hadine Joffe, MD, MSc1
ucts for Postmenopausal Use in the United States Gloria Richard-Davis, MD11
Steven R. Goldstein, MD, NCMP12
and Canada (oral continuous-cyclic, oral continuous- Isaac Schiff, MD1
combined, oral intermittent-combined, and transder- Wulf H. Utian, MB, Bch, PhD, DSc (Med)4
mal continuous-combined regimens)
Table 6. Progestogens Available in the United States and Canada
(Detailed listing of products, composition, and dosages)
Table 7. Estrogen-Progestogen Therapy Regimens, Terminology
(sequential, continuous-combined, intermittent-combined)
Table 8. Minimum Progestogen Dosing Requirements for En-
dometrial Protection With Standard Estrogen Dosing
Table 9. FDA-approved BBioidentical[ Hormone Products This document was approved by the 2013-2014 NAMS BOARD OF
(FDA-approved products containing estradiol and/or TRUSTEES (for coauthors, affiliations and disclosures are listed above):
progesterone) Margery LS Gass, MD, NCMP (Executive Director); Howard N Hodis,
MD, University of Southern California, Los Angeles, CA (no disclosures);
Table 10. Pros and Cons of Hormone Therapy Routes of Andrew M Kaunitz, MD, FACOG, NCMP; Sheryl A Kingsberg, PhD;
Administration (oral, transdermal, vaginal) Lynnette Leidy Sievert, BSN, PhD, University of Massachusetts, Amherst,
MA (no disclosures); James H Liu, MD; Pauline M Maki, PhD (Uni-
*Note that information on hormone therapy formulations versity of Illinois at Chicago, Chicago, IL (Consultant: Pfizer; Speaking
and dosages is regularly updated on the NAMS website at: Honorarium: Abbott); JoAnn E Manson, MD, DrPH, NCMP; Diane T
Pace, PhD, FNP-BC, FAANP; Gloria Richard-Davis, MD, FACOG, Marla
http://www.menopause.org/docs/default-source/2014/nams- Shapiro, MDCM, CCFP, MHSc, FRCP(C), FCFP, NCMP; Isaac Schiff,
ht-tables.pdf). MD (Ex Officio); ); Peter F Schnatz, DO, FACOG, FACP; Jan L Shifren,
MD; Wulf H Utian, MD, PhD, DSc(Med) (Ex Officio).

Disclaimer: This Application is intended for informational purposes 1

Harvard Medical School; 2New York City; 3University of Toronto;
only and is not intended as a substitute for professional medical judg- 4
Case Western Reserve University; 5University of California, San Diego;
ment, diagnosis, or treatment. Users of the app are asked to read and 6
University of Virginia, Charlottesville; 7University of Florida College of
accept an End User License Agreement, available on the app.
Medicine-Jacksonville; 8University of Memphis/Loewenberg School of
Nursing; 9University of California, San Francisco; 10Jefferson Medical
Financial disclosure/conflicts of interest: JEM, JMA, JLS, MLSG, College;11University of Arkansas Medical Sciences, Little Rock; and
12
PFS, IS, and WHU report no disclosures. MS is a consultant/advisory New York University School of Medicine.
board member for Amgen, Merck, Pfizer and serves on the speakers’
bureau for Amgen, Merck, Novo Nordisk, and Pfizer. CAS has served
as a consultant to Pfizer. JVP is a consultant (fees to the University of
Virginia) for Pfizer Inc, TherapeuticsMD, Noven, NovoNordisk, and
Shionogi. AMK is a consultant/advisory board member for Actavis, REFERENCES
Bayer, Teva, and has received grant support from Bayer, Endoceutics,
Noven, Teva, and TherapeuticsMD. DTP is a consultant/advisory 1. Manson JE, Bassuk SS. The menopause transition and postmenopausal
board member for Hologic and Pfizer. RK is a consultant for Amgen hormone therapy. In: Longo DL, Fauci AS, Kasper DL, Hauser SL,
and Merck, is a consultant for and has received payment for lectures/ Jamison JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine,
service on speakers’ bureaus for, Pfizer, Novo Nordisk, Noven, and McGraw-Hill: New York, 2011.
Shionogi, and receives research support from TherapeuticsMD (fees 2. North American Menopause Society. The 2012 Hormone Therapy Posi-
to Sutter Research Institution). SAK serves as a consultant/advisory tion Statement of the North American Menopause Society. Menopause
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4. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone
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speakers’ bureaus for, Shionogi, Pfizer, Noven, and JDS Therapeu- 5. Santen RJ, Allred DC, Ardoin SP, et al. Postmenopausal hormone ther-
tics, and is a consultant and has received payment for service for apy: an Endocrine Society scientific statement. J Clin Endocrinol Metab
Smith and Nephew. 2010;95(Suppl 1):s1-s66.

6 Menopause, Vol. 22, No. 3, 2015 * 2014 The North American Menopause Society

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
 EDITORIAL

6. Bray PF, Larson JC, Lacroix AZ, et al. Usefulness of baseline lipids and C- 9. Bassuk SS, Manson JE. Menopausal hormone therapy and cardiovascular
reactive protein in women receiving menopausal hormone therapy as predic- disease risk: utility of biomarkers and clinical factors for risk stratifica-
tors of treatment-related coronary events. Am J Cardiol 2008;101:1599-1605. tion. Clin Chem 2014;60:68-77.
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