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Footnote
<sup>1</sup> <b>NAMS 2014.</b> Guideline & mobile app for menopausal sx mgmnt & hormonal/nonhormonal therapy decision making from NAMS. <i>Menopause: The Journal of The North American Menopause Society.</i> 2014. Vol. 22, No. 3, pp. 000/000. <a href=http://www.menopause.org/docs/default-source/2014/menopro-app-algorithm-2014.pdf><b><u>PDF</b></u></a><br><br>
These women may need additional clinical eval before applying guideline: <45 yo, not clearly menopausal, s/p endometrial ablation, w/ progestin-releasing intrauterine device/system, s/p hysterectomy w/o removal of ovaries; additional eval may include hCG, FSH, TSH, prolactin, other tests. This guideline can be used for women s/p BL oophorectomy, @ any age.
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<sup>2</sup> <b>NAMS 2014.</b> Mod-to-severe = bothersome enough to interfere w/ daily activities, impair QOL, or interrupt sleep. All women encouraged to try lifestyle mod x≥3 mo before beginning HT/other pharmacologic tx.
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<sup>3</sup> ACC/AHA CVD score: tools.cardiosource.org/ASCVD-Risk-Estimator/
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<sup>4</sup> <b>NAMS 2014.</b> If hormonal tx chosen: begin @ lower doses; if inadequate sx relief at 3 to 6mo, adjust dose/change to different tx. Regularly review needs: if continued preference for HT, reassess ≥1x every 6 to 12mo or if health status changes. NAMS generally recommends duration consistent w/ tx goals but avoiding durations >7y for estrogen-alone, >5y for E+P. Extended duration may be appropriate in selected pts.
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<sup>5</sup> <b>NAMS 2014.</b> If >10y past menopause: generally not good candidates for start/1st use of systemic HT; however, individualized decision-making required for starting/continuing/restarting systemic HT beyond 60 yo or >1 decade past menopause.
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<sup>6</sup> <b>NAMS 2014.</b> Transdermal vs PO estrogen: If obese/DM/MetSyn: if otherwise HT candidate, may do better w/ transdermal. If high TG (≥400 mg/dL) or GB dz, avoid PO estrogen, but transdermal may be an option. Transdermal may be preferable for pts w/ MetSyn/other significant CVD risks, as it has less adverse effect on clotting factors/TGs/inflammation factors vs PO estrogen; it may be less likely to ↓libido vs PO estrogen.
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<sup>7</sup> <b>NAMS 2014.</b> If ≥1 1st-degree relative w/ breast CA, or otherwise @ increased risk (cancer.gov/bcrisktool) may want to consider nonhormonal tx.
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<sup>8</sup> <b>NAMS 2014.</b> HT contraindications include: unexplained vag bleeding; liver dysfxn/dz; active/hx DVT/PE; clotting disorder/thrombophilia; untreated HTN; hx breast/endometrial CA/other estrogen-dependent tumor; hypersensitivity to HT, hx CHD/stroke/TIA. Women on thyroid meds may need dose adjustments.
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<sup>9</sup> <b>NAMS 2014.</b> If intact uterus: CE+3rd-gen SERM (CE 0.45 mg + bazedoxifene 20 mg daily) is an FDA-approved option for pts w/ intact uterus, esp if concerned about breast tenderness/density or uterine bleeding; contraindications similar to systemic HT.
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<sup>10</sup> <b>NAMS 2014.</b> Women @ high osteoporotic fx risk who are unable to tolerate standard preventive meds may also be HT candidates. HT for osteoporosis prevention is controversial.
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<sup>11</sup> <b>NAMS 2014.</b> Other SSRIs/SNRIs (off-label): venlafaxine 75-150 mg/day; escitalopram 10-20 mg/day; citalopram 10-30 mg/day; desvenlafaxine 50 mg/day; paroxetine HCl 10-20 mg/day; paroxetine CR 12.5-25 mg/day. Check product labeling for comprehensive contraindications/cautions.
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<sup>12</sup> <b>NAMS 2014.</b> Gabapentin 900-2400 mg/day (divided TID); pregabalin 150-300 mg/day (divided BID); clonidine 100 mcg/day. Check product labeling for comprehensive contraindications/cautions.
These women may need additional clinical eval before applying guideline: <45 yo, not clearly menopausal, s/p endometrial ablation, w/ progestin-releasing intrauterine device/system, s/p hysterectomy w/o removal of ovaries; additional eval may include hCG, FSH, TSH, prolactin, other tests. This guideline can be used for women s/p BL oophorectomy, @ any age.
<br><br>
<sup>2</sup> <b>NAMS 2014.</b> Mod-to-severe = bothersome enough to interfere w/ daily activities, impair QOL, or interrupt sleep. All women encouraged to try lifestyle mod x≥3 mo before beginning HT/other pharmacologic tx.
<br><br>
<sup>3</sup> ACC/AHA CVD score: tools.cardiosource.org/ASCVD-Risk-Estimator/
<br><br>
<sup>4</sup> <b>NAMS 2014.</b> If hormonal tx chosen: begin @ lower doses; if inadequate sx relief at 3 to 6mo, adjust dose/change to different tx. Regularly review needs: if continued preference for HT, reassess ≥1x every 6 to 12mo or if health status changes. NAMS generally recommends duration consistent w/ tx goals but avoiding durations >7y for estrogen-alone, >5y for E+P. Extended duration may be appropriate in selected pts.
<br><br>
<sup>5</sup> <b>NAMS 2014.</b> If >10y past menopause: generally not good candidates for start/1st use of systemic HT; however, individualized decision-making required for starting/continuing/restarting systemic HT beyond 60 yo or >1 decade past menopause.
<br><br>
<sup>6</sup> <b>NAMS 2014.</b> Transdermal vs PO estrogen: If obese/DM/MetSyn: if otherwise HT candidate, may do better w/ transdermal. If high TG (≥400 mg/dL) or GB dz, avoid PO estrogen, but transdermal may be an option. Transdermal may be preferable for pts w/ MetSyn/other significant CVD risks, as it has less adverse effect on clotting factors/TGs/inflammation factors vs PO estrogen; it may be less likely to ↓libido vs PO estrogen.
<br><br>
<sup>7</sup> <b>NAMS 2014.</b> If ≥1 1st-degree relative w/ breast CA, or otherwise @ increased risk (cancer.gov/bcrisktool) may want to consider nonhormonal tx.
<br><br>
<sup>8</sup> <b>NAMS 2014.</b> HT contraindications include: unexplained vag bleeding; liver dysfxn/dz; active/hx DVT/PE; clotting disorder/thrombophilia; untreated HTN; hx breast/endometrial CA/other estrogen-dependent tumor; hypersensitivity to HT, hx CHD/stroke/TIA. Women on thyroid meds may need dose adjustments.
<br><br>
<sup>9</sup> <b>NAMS 2014.</b> If intact uterus: CE+3rd-gen SERM (CE 0.45 mg + bazedoxifene 20 mg daily) is an FDA-approved option for pts w/ intact uterus, esp if concerned about breast tenderness/density or uterine bleeding; contraindications similar to systemic HT.
<br><br>
<sup>10</sup> <b>NAMS 2014.</b> Women @ high osteoporotic fx risk who are unable to tolerate standard preventive meds may also be HT candidates. HT for osteoporosis prevention is controversial.
<br><br>
<sup>11</sup> <b>NAMS 2014.</b> Other SSRIs/SNRIs (off-label): venlafaxine 75-150 mg/day; escitalopram 10-20 mg/day; citalopram 10-30 mg/day; desvenlafaxine 50 mg/day; paroxetine HCl 10-20 mg/day; paroxetine CR 12.5-25 mg/day. Check product labeling for comprehensive contraindications/cautions.
<br><br>
<sup>12</sup> <b>NAMS 2014.</b> Gabapentin 900-2400 mg/day (divided TID); pregabalin 150-300 mg/day (divided BID); clonidine 100 mcg/day. Check product labeling for comprehensive contraindications/cautions.
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Patient Type Detail Header (Long)
For menopausal<sup>1</sup> pts ≥45 yo<sup>1</sup> w/ mod-to-severe<sup>2</sup> vasomotor sx inadequately responsive to behavior mod:<sup>2</sup> Assess 10-yr CVD risk<sup>3</sup> and menopause duration<sup>4,5,6</sup>