{"paper_id":"cdf72dbc-43e2-4a7b-a73a-b28dc1987761","body_text":"88\nThis is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International  \n(CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/)\nREVIEW PAPER\nDOI: https://doi.org/10.5114/pm.2021.107103\nMenopause Rev 2021; 20(2): 88-98\nIntroduction \nMenopause is defined as the last menstrual period \nfollowed by no menstruation for the next 12 months \nwith no pathological causes of such a condition \nidentified. Menopause is one of the most important \nevents in the female reproductive life cycle, a tran-\nsition from the reproductive to the nonreproductive \nstage.\n This introduces several physiological changes \nthat affect a woman’s further life permanently, set-\nting the stage for aging [1, 2]. \nIn the United States, the median age at which \nmenopause occurs is 52, but it can vary between  \n40 and 58 years of age [3]. The mean age of the \nonset of natural menopause in Polish population is \n51.25 [4]. Over the last 25 years, a slowdown in de-\nmographic development in Poland and significant \nchanges in the age structure of its inhabitants have \nbeen observed. At the end of 2014, the population of \nPoland reached 38.5 million, including over 8.5 mil-\nlion people aged 60 and above (over 22%). Among \nthe elderly population, the majority are women \n(59%). Life expectancy for people aged 60 has also \nincreased over the past 23 years. The life expectancy \nof 60-year-olds has extended by 4.1 years for men \nPostmenopausal women in gynecological care\nMagdalena Pertyńska-Marczewska1, Tomasz Pertyński2\n1Private Practice, London, United Kingdom \n2Faculty of Health Science, Mazovian Public University in Plock, Poland\nAbstract\nMenopause is one of the most important events in the female reproductive life cycle, being a transition \nfrom the reproductive to the nonreproductive stage. It is a milestone that may have a negative influence on \nquality of life and one that brings in several physiological changes that affect the life of a woman permanently. \nAccording to a Polish epidemiological forecast, in 2050 the average female life expectancy will be 87.5, which \nis 6.4 years longer than today. Thus, the life expectancy of women who will be 60 or older in 2050 will also \nextend. Therefore, strategies need to be optimized to maintain postreproductive health, in part because of \nincreased longevity. The general gynecologist can expect to see more elderly female patients as the popula-\ntion continues to age. Office management of the gynecologic problems of geriatric women requires sensi-\ntivity to the special needs of this group. Nowadays, most women spend more than one-third of their lives \nafter menopause; therefore there is plenty of opportunity for gynecologists to cater to the needs of post-\nmenopausal women. It is in their scope of practice to help postmenopausal women through “healthy aging”. \nIn this review we look into screenings, early identification, lifestyle modifications and appropriate intervention \nthat may prevent many chronic conditions that cause morbidity and mortality during the postmenopausal years.\nKey words: postmenopause, screening, healthy aging.\nand 4.5 for women since 1991. According to an ep-\nidemiological forecast, in 2050 the average female \nlife expectancy will be 87.5, which is 6.4 years longer \nthan today. Thus, the life expectancy of people who \nwill be 60 or older in 2050 will also extend [5]. \nA report by the Population Reference Bureau es-\ntimated that 40 million people in the U.S. are 65 or  \nolder – a number that is expected to reach 89 mil-\nlion by 2050 [6] – and by the year 2025, the number \nof postmenopausal women is expected to rise to  \n1.1 billion worldwide [7]. These changing demograph-\nics raise the problem of providing gynecologic care \nfor these women and the issue of the role of the gy-\nnecologist as their primary care physician [8], since \nas experts in women’s health care, gynecologists \nare uniquely trained to guide, counsel, diagnose, \nand treat women across their entire lifetime [9].  \nIt is in their scope of practice to help postmenopaus-\nal women through “healthy aging”.\nHealthy aging includes survival to old age, delay \nof the onset of non-communicable diseases and op-\ntimal functioning for a maximal period at individual \nlevels of cells and body systems [7].\nAn annual “well-woman” visit provides an excel-\nlent opportunity to counsel patients about maintain-\nCorresponding author: \ndr n med. Magdalena Pertyńska-Marczewska, e-mail: m_pertynska@yahoo.com Submitted: 22.02.2021\nAccepted: 28.04.2021\n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n89\ning a  healthy lifestyle and minimizing health risks. \nThe periodic well-woman care visit should include \nscreening, evaluation, and counseling [9].\nPreventive care recommendations \nScreenings, early identification, lifestyle modifi-\ncations and appropriate intervention may prevent \nmany chronic conditions that cause morbidity and \nmortality during the postmenopausal years [10].\nOsteoporosis screening\nOsteoporosis is characterized by low bone mass, \nstructural deterioration, and porous bone, which are \nassociated with higher fracture risk [11]. Bone loss, \nrelated to declining estrogen levels, increases frac-\nture risk in postmenopausal women, who make up \nthe majority of osteoporosis cases [12]. For example, \nthe aging U.S. population is predicted to contribute \nto as much as a 50% increase in prevalence by 2025 \n[13]. Therefore, early detection and treatment of \nhigh-risk patients with antiresorptive medications \n[11], and optimization of bone health throughout life \ncan help prevent osteoporosis. \nWorldwide, osteoporosis causes more than 9 million \nfractures a  year, meaning there is a  fragility fracture \nevery 3 s [14]. In just the 6 largest European countries \nthe total number of fragility fractures is estimated to \nincrease from 2.7 million in 2017 to 3.3 million in 2030, \nan increase of 23.3% [15]. About one-tenth of women in \ntheir 60s, one-fifth of women in their 70s, two-fifths of \nwomen in their 80s and two-thirds of women in their \n90s have osteoporosis and an increased risk of fragility \nfracture [16].\n In the general Polish population, over 2 million peo-\nple over the age of 50 (every third woman and every \nfifth man) suffer from osteoporosis, in the majority of \nthe cases, complicated by fracture [17].\nIt is important to remember that fractures at the hip \nand vertebrae are among the most common and seri-\nous sites of osteoporotic fracture. Fragility fractures of \nthe humerus, forearm, ribs, tibia (in women, but not in-\ncluding ankle fractures), pelvis and other femoral frac-\ntures after the age of 50 are fractures associated with \nlow BMD [18]. \nCreated in 1984, the U.S. Preventive Services Task \nForce (USPSTF) is an independent group of national \nexperts in prevention and evidence-based medicine \nthat works to improve the health of all Americans by \nmaking evidence-based recommendations about clini-\ncal preventive services such as screenings, counseling \nservices, or preventive medications. \nGuidelines from the USPSTF recommend screening \nfor osteoporosis with bone measurement testing to \nprevent osteoporotic fractures.\nDiagnostic and treatment criteria for osteoporosis \nrely on hip and lumbar spine dual-energy X-ray absorp-\ntiometry measurements (DXA). The guidelines state \nthat dual-energy X-ray absorptiometry screening is \nrecommended for women 65 years and older, and the \nUSPSTF endorsed use of the Fracture Risk Assessment \nTool FRAX to identify screening candidates among \nyounger postmenopausal women aged 50 to 64 years. \nThe recommended threshold score is 9.3% [19, 20].\nDXA provides measurement of bone mineral density \n(BMD), and most treatment guidelines use central DXA \nto define osteoporosis and the threshold at which to \nstart drug therapies to prevent osteoporotic fractures. \nThe major change in the current recommendation \nis that the USPSTF expanded its consideration of ev-\nidence related to fracture risk assessment, with or \nwithout BMD testing [20]. For women 65 and older, the \nUSPSTF found convincing evidence that screening can \ndetect osteoporosis and that treatment of women with \nosteoporosis can provide at least a  moderate benefit \nin preventing fractures. For postmenopausal women \nyounger than 65 who are at increased risk of osteopo-\nrosis, the USPSTF found adequate evidence that screen-\ning can detect osteoporosis and that treatment pro-\nvides a moderate benefit in preventing fractures [20].\nIn addition to adequate calcium and vitamin D in-\ntake and weight-bearing exercise, multiple drug ther -\napies are approved to reduce fracture risk, including \nbisphosphonates, parathyroid hormone, raloxifene, \nand estrogen [20]. According to the USPSTF , effective \nfall prevention measures include weight-bearing exer -\ncise and balance training three times per week, mus-\ncle strengthening twice per week, and 150 minutes per \nweek of moderate-intensity or 75 minutes per week of \nvigorous-intensity aerobic physical activity. With a  re-\nvised scope of review, as well as newer evidence from \ntrials reporting no benefit, the USPSTF found that vita-\nmin D supplementation has no benefit in fall prevention \nin community-dwelling older adults not known to have \nvitamin D deficiency or insufficiency. Thus, the USPSTF \nnow recommends against vitamin D supplementation \nfor the prevention of falls in community-dwelling older \nadults [20]. However, The National Institute on Aging \nrecommends vitamin D supplementation of at least \n800 IU per day for persons with vitamin D deficiency or \nwho are at increased risk for falls [21]. \nCardiovascular disease screening \nCardiovascular disease (CVD) is the leading cause of \ndeath and disability in women older than 50, exceeding \nthe number of deaths from malignant neoplasms, dia-\nbetes mellitus, and chronic lower respiratory diseases \ncombined [22]. The prevalence of CVD increases rapidly \nat the onset of menopause and continues to increase \nthrough the post-menopausal period [10].\n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n90\nPeriodic cardiovascular risk assessment in post-\nmenopausal women can identify risk factors and enable \nimplementation of risk reduction strategies [10, 23]. The \n2019 American College of Cardiology/American Heart \nAssociation (ACC/AHA) guideline recommends using \nthe pooled cohort risk assessment equations (http:// \ntools.acc.org/ASCVD-Risk-Estimator/) every three to \nfive years to calculate the 10-year risk of atherosclerotic \ncardiovascular disease (ASCVD), including myocardial \ninfarction and stroke [24].\nSince 2008 the USPSTF has strongly recommended \nroutinely screening women 45 and older for lipid disor-\nders and treating abnormal lipid levels in persons who \nare at increased risk of coronary heart disease (CHD). \nScreening for diabetes with fasting plasma glucose is \nindicated for women with risk factors for CHD, such as \nhypertension and hyperlipidemia [25]. \nThe ACC/AHA recommend that all adults should \nconsume a healthy diet that emphasizes the intake of \nvegetables, fruits, nuts, whole grains, lean vegetable \nor animal protein, and fish, and minimizes the intake \nof trans fats, red meat and processed red meats, refined \ncarbohydrates, and sweetened beverages. For over -\nweight and obese adults, counseling and caloric restric-\ntion are recommended for achieving and maintaining \nweight loss [24].\nIn 2015 the USPSTF issued an update to the 2008 \nrecommendation statement in which the USPSTF rec-\nommended screening for diabetes in asymptomatic \nadults with hypertension (defined as sustained blood \npressure of > 135/80 mm Hg). New evidence led the \nUSPSTF to conclude that there is a moderate net bene-\nfit to measuring blood glucose in adults who are at in-\ncreased risk for diabetes [26]. Additionally, data suggest \nthat smoking cessation after an MI and treatment of \nhypertension and hyperlipidemia lower the risk for CHD \nevents in women [27]. \nThe USPSTF and ACC/AHA recommend aspirin and \nstatins for primary prevention of CVD in selected high-\nrisk patients who are at low risk of adverse effects from \nthese medications [28, 29].\nCancer screening\nBreast cancer\nThere is consistency across multiple organization-\nal guidelines that average-risk women benefit from \nscreening mammography at least every other year from \n50 to 74 years of age [30]. The evidence that screening \nreduces mortality from breast cancer is strongest for \nwomen 50 to 69 years of age. There is no evidence of \nbenefit for women older than 75 years, but the USPSTF \nrecommends screening women older than 70 years \nwho have a reasonable life expectancy [31].\nThe USPSTF concludes that while there are risks as-\nsociated with mammography, the benefit of screening \nmammography outweighs the harms by at least a mod-\nerate amount from age 50 to 74 years and especially for \nwomen in their 60s. For women in their 40s, the benefits \nstill outweigh the harms, but to a smaller degree; this \nbalance may therefore be more subject to individual \nvalues and preferences than it is for older women [32]. \nOn the other hand, the American Cancer Society recom-\nmends performing mammography annually in women \n45 to 54 years of age, biennially in women 55 years and \nolder, and to not screen women with a life expectancy \nof less than 10 years [30].\nAdditionally, the American College of Obstetricians \nand Gynecologists recommends a  mammography an-\nnually beginning at 40 years of age [33].\nIn recent years, a newer type of mammogram \ncalled digital breast tomosynthesis (commonly known \nas three-dimensional [3D] mammography) has become \nmuch more common, although it is not available in all \nbreast imaging centers. Many studies have found that 3D \nmammography appears to reduce the likelihood of be-\ning called back for follow-up testing. It also appears to re-\nveal more breast cancers, and several studies have shown \nthat it can be helpful for women with denser breasts [34].\nThe USPSTF recommends that clinicians offer to \nprescribe risk-reducing medications, such as tamoxifen, \nraloxifene, or aromatase inhibitors, to women who are \nat increased risk for breast cancer and at low risk for ad-\nverse medication effects [35]. Based on expert opinion, \nthe American Cancer Society and the National Compre-\nhensive Cancer Network include aromatase inhibitors, \nexemestane, or anastrozole as additional options [36]. \nIn Poland, breast cancer is the most common ma-\nlignancy in women (17 379 cases in 2014; standardized \nincidence rate 51.6/100,000 [37]) and the second cause \nof death due to cancer among Polish women [37].\nThe recommendations of the Polish Gynecological \nSociety (23.2.2005)  state that every woman between  \n45 and 50 year of age should have a  mammography \nperformed every 2 years. From the age of 50 the mam-\nmography should be performed annually. Additionally, \nthe experts pointed out that the breast ultrasound is \nnot an examination that replaces mammography but is \na supplementary part of the diagnostic process. \nCervical cancer\nIn the elderly population, cancer is one of the pre-\ndominant causes of mortality and morbidity, and its in-\ncidence increases with ageing. Sixty percent of all can-\ncers and 70% of cancer-related deaths occur in patients \naged 65 years and over [38]. \nIn patients aged 65 and over, cervical cancer has \nmortality rates ranging between 40 and 50%. However, \nthere is evidence that regular screening reduces cer -\nvical cancer risk at a rate of 80% and early detection \nthrough routine Papanicolaou (Pap) testing and treat-\nment of precursor cervical intraepithelial neoplasia can \nlower mortality from cervical cancer [39, 40].\n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n91\nAccording to American Cancer Society recommen-\ndations, screening tests for cervical cancer should be \ninitiated within the first 3 years from the first sexual in-\ntercourse or at most at the age of 21. Every year obstetric \nexamination and a Pap smear test should be performed. \nIf the last successive 3 screening test results are within \nnormal limits, then screening tests can be done every \n2–3 years. Postmenopausal women should receive hu-\nman papillomavirus and cytology co-testing every five \nyears, or cytology alone every three years, until the age \nof 65 years [41]. If the last 2 tests yield negative results, \nscreening should be stopped when the patient reaches \n65 years of age. Once screening has stopped, it should \nnot resume in women older than 65 years, even if they \nreport having a new sexual partner [42].\nScreening should be discontinued in women who \nundergo total hysterectomy for benign disease [42]. \nAdditionally, shared guidelines from the American \nCancer Society, American Society for Colposcopy and \nCervical Pathology, and the American Society for Clin-\nical Pathology (ACS/ASCCP/ASCP) state that routine \nscreening should continue for at least 20 years after \nspontaneous regression or appropriate management of \na  precancerous lesion, even if this extends screening \npast age 65 years. \nIn 2018, the USPSTF updated its screening guide-\nlines [42]. In addition to continuing to recommend tri-\nennial cytology (Papanicolaou tests) for women aged \n21 to 29 years followed by either continued triennial \ncytology or adding a test for high-risk types of HPV ev-\nery 5 years from ages 30 to 65 years, the USPSTF en-\ndorsed a strategy of hrHPV testing alone every 5 years \nfor women aged 30 to 65 years. The USPSTF stated that \nreferring all women with abnormal test results directly \nfor colposcopy would lead to a  much greater number \nof colposcopies, but it did not recommend any particu-\nlar triage strategy for women with a positive test result \nfor hrHPV; the Society of Gynecologic Oncology rec-\nommends triaging these women with HPV genotyping \n(tests for HPV types 16 or 18) [43].\nEndometrial cancer and intrauterine pathologies\nEndometrial cancer is the most common gynecolog-\nic cancer in developed countries and accounts for nearly \n5% of cancer cases and more than 2% of deaths due to \ncancer in women worldwide [44].\nBetween 4 and 11% of postmenopausal women will \nexperience postmenopausal bleeding (PMB) [45], ac-\ncounting for approximately two-thirds of all gynecolog-\nic visits among perimenopausal and postmenopausal \nwomen [46]. However, the risk of endometrial cancer \nin women with PMB varies widely in individual studies \nfrom 3 to 25% [47].\nThe most common causes of uterine bleeding in \npostmenopausal women are benign and include vagi-\nnal or endometrial atrophy, cervical polyps, and submu-\ncosal fibroids [45]. \nIn many European countries, guidelines recom-\nmend transvaginal ultrasound (TVUS) as the first-line \napproach in evaluation of postmenopausal bleeding, \nwith histologic assessment indicated for women with \na  thickened endometrium based on cutoffs ranging \nfrom 3 to 5 mm [46, 48].\n In the United States, evaluation of PMB begins with \na screening TVUS [49]. Findings of an endometrium of  \n≤ 4 mm on TVUS indicate a low likelihood of the pres-\nence of endometrial cancer, and treatment for atrophy \nor changes to the hormone replacement therapy regi-\nmen constitute reasonable first-line management; en-\ndometrial biopsy is not recommended [50]. \nHowever, because rare cases of endometrial car -\ncinoma (particularly type II) can present with an en-\ndometrial thickness of less than 3 mm, persistent or \nrecurrent uterine bleeding should prompt a histologic \nevaluation of the endometrium regardless of endome-\ntrial thickness [49].\nFor patients with persistent PMB or thickened en-\ndometrium ≥ 4 mm on TVUS, biopsy sampling of the \nendometrium should be performed.\nA negative tissue biopsy result in women with PMB \nis not considered to be an endpoint, and further evalu-\nation with hysteroscopy to evaluate for focal disease is \nimperative. The results of endometrial biopsy are only \nan endpoint to the evaluation of PMB when atypical \nhyperplasia or endometrial cancer is identified [49, 50]. \nHysteroscopy is confirmed as the gold standard in \nthe assessment of abnormal uterine bleeding in meno-\npause, permitting the elimination of false-negative re-\nsults of blind biopsy through direct visualization of the \nuterine cavity and the performance of targeted biopsy \nin case of doubt [51]. It permits full visualization of the \nendocervix, endometrial cavity and tubal ostia, allow-\ning visual diagnosis of focal endometrial lesions that \nare missed with endometrial sampling, TVS or saline \ninfusion sonohysterography [51].\n Two  types of the procedure are generally per -\nformed: diagnostic and operative hysteroscopy. Diag-\nnostic hysteroscopy allows visualization of the endo-\ncervical canal, endometrial cavity, and fallopian tube \nostia. Operative hysteroscopy incorporates the use of \nmechanical, electrosurgical, or laser instruments to \ntreat intracavitary pathology, thus offering a “see-and-\ntreat” approach [52].\nAdvances in technology have led to miniaturization \nof high-definition hysteroscopes without compromis-\ning optical performance, thereby making hysteroscopy \na simple, safe and well-tolerated office procedure. The \nnew surgical technology such as bipolar electrosurgery, \nendometrial ablation devices, hysteroscopic steriliza-\ntion, and morcellators has revolutionized this surgical \nmodality [53]. The modern development of hysterosco-\npy transformed the approach to intrauterine patholo-\ngies from a blind procedure under general anesthesia \n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n92\nto an outpatient procedure performed under direct \nvisualization, offering a  comprehensive diagnosis and \nmanagement approach [45].\nColorectal cancer\nThe stage at which colorectal cancer is detected has \na substantial effect on survival. The five-year survival \nrate is approximately 91% with localized disease but \ndrops to 6% among individuals presenting with distant \nmetastasis [54].\nColorectal cancer has a male predominance and is \nstrongly associated with age; 80% of new cases occur in \npatients aged over 60. Obesity and limited exercise are \nstrong risk factors. Diets low in fruit and vegetables and \nfiber and high in red meat have also been associated \nwith an increased risk. Patients with one first-degree \nrelative under 45 or two first-degree relatives of any age \nwho developed colorectal cancer have an approximate \nlifetime risk of developing the disease of 16–25% in men \nand 10–15% in women. Having one first-degree relative \nwho developed the disease after the age of 65 barely \nincreases lifetime risk. Patients with ulcerative colitis \nand Crohn’s colitis also have an increased lifetime risk \nof colorectal cancer [55].\nThe American Cancer Society 2018 guideline for \ncolorectal cancer screening recommends that aver -\nage-risk adults aged 45 years and older undergo regu-\nlar screening with either a high-sensitivity stool-based \ntest or a structural (visual) examination, based on per -\nsonal preferences and test availability. As a part of the \nscreening process, all positive results on non-colonos-\ncopy screening tests should be followed up with timely \ncolonoscopy [56]. \nThe USPSTF recommends screening for colorectal \ncancer beginning at 50 years of age and continuing \nthrough 75, then individualized decision making in pa-\ntients 76 to 85 years of age [57]. High-risk women who \nmay require more intensive screening and/or genetic \ntesting include those with a history of genetic disorders \n(e.g., familial adenomatous polyposis), inflammatory \nbowel disease, or a previous adenomatous polyp or col-\norectal cancer [57].\nSexually transmitted diseases screening\nOlder women are often sexually active, but physi-\ncians caring for older women rarely address sexual con-\ncerns. Although women’s desire for sex declines with \nage, a majority of older women rate sex as having im-\nportance in their lives [58]. \nFor example, in England, approximately 7% of new \nsexually transmitted disease (STD) diagnoses in 2018 \nwere among individuals aged 45–64 years [59]. Accord-\ning to American data from 2005, an estimated 65% of \nwomen 51 to 64 years of age engage in sexual inter -\ncourse at least once per week [60].\nIn a brand new British paper [61] the authors stat-\ned that the identified barriers to STD risk prevention \namong midlife adults include low knowledge about \nSTDs, prioritization of intimacy above STD risks in new \nrelationships, [62] stigmatization of STDs among older \nadults [62], and reduced motivation to consider safer \nsex following removal of pregnancy risk due to meno-\npause or permanent contraception [63]. Interestingly, \none American study found that 1% of widowed women \n67 to 99 years of age developed an STD during a nine-\nyear study [64]. \nThe USPSTF recommends that high-risk sexually ac-\ntive women receive intensive behavioral counseling to \nreduce STD risk, and annual screening for chlamydia, \ngonorrhea, syphilis, and human immunodeficiency vi-\nrus (HIV) infection [65].\nGenitourinary syndrome\nThe genitourinary syndrome of menopause (GSM) \nis a  term that describes various menopausal symp-\ntoms and signs including not only genital symptoms \n(dryness, burning, and irritation) and sexual symptoms \n(lack of lubrication, discomfort or pain, and impaired \nfunction) but also urinary symptoms (urgency, dysuria, \nand recurrent urinary tract infections) [66].\nA majority of women suffering from GSM are of old-\ner age, with 50–70% of postmenopausal women being \nsymptomatic at least to some degree [67].\nUnlike other menopausal symptoms, GSM is a chron-\nic, progressive condition of the vulvovaginal and lower \nurinary tract [68]. According to the newest statement \nfrom the North American Menopause Society (NAMS), \nGMS affects approximately 27 to 84% of postmenopaus-\nal women and can significantly impair health, sexual \nfunction, and quality of life [69].\nThese symptoms are directly related to the reduced \ncirculating estrogen levels after menopause. Estrogen \nreceptors (ERs; both α and α) are present in the vagina, \nvulva, musculature of the pelvic floor, endopelvic fascia, \nurethra, and bladder trigone during reproductive life; \ntheir levels decline with menopause and may be re-\nstored by estrogen treatment [70]. As a result of estro-\ngen deficiency after menopause, anatomic and histo-\nlogic changes occur in female genital tissues, including \nreduction in the content of collagen and hyaluronic acid \nand in the levels of elastin, thinning of the epithelium, \nalterations in the function of smooth muscle cells, in-\ncrease in the density of connective tissue, and fewer \nblood vessels. These changes reduce elasticity of the \nvagina, increase vaginal pH, lead to changes in vaginal \nflora, diminish lubrication, and increase vulnerability to \nphysical irritation and trauma [70].\nThe NAMS noted that GSM is likely underdiagnosed \nand undertreated, but in most cases, symptoms can \nbe effectively managed. The diagnosis and evaluation  \n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n93\nof GSM are clinical and  mostly established through \na thorough medical history and physical pelvic exam-\nination [71]. \nAdditionally, two instruments of measurement prop-\nerties of patient-reported outcome measures specific \nfor genitourinary symptoms (the Vulvovaginal Symp-\ntoms Questionnaire and the Day-to-Day Impact of Vag-\ninal Aging (DIVA) Questionnaire) have been shown to \nbe valid after a thorough assessment. These two tools \ncan be efficiently used for the evaluation of GSM symp-\ntoms and measurement of their impact on the QOL of \npatients [72, 73].\nA number of over-the-counter and government-ap-\nproved prescription therapies available in the United \nStates and Canada demonstrate diverse effectiveness, \ndepending on the severity of symptoms. These include \nvaginal lubricants and moisturizers, vaginal estrogens \nand dehydroepiandrosterone (DHEA), systemic hor -\nmone therapy, and the estrogen agonist/antagonist os-\npemifene. Low-dose vaginal estrogens, vaginal DHEA, \nsystemic estrogen therapy, and ospemifene are effec-\ntive treatments for moderate to severe GSM. When \nlow-dose vaginal estrogen or DHEA or ospemifene is \nadministered, a progestogen is not indicated; however, \nendometrial safety has not been studied in clinical tri-\nals beyond 1 year. There are insufficient data at present \nto confirm the safety of vaginal estrogen or DHEA or \nospemifene in women with breast cancer; management \nof GSM should consider the woman’s needs and the \nrecommendations of her oncologist [69].\nAdditionally, because of the insufficient number \nof placebo-controlled trials of energy-based therapies,  \nincluding laser, the NAMS cannot draw conclusions on \nefficacy and safety or make treatment recommenda-\ntions [69].\nUrinary incontinence and urinary tract infections \nThe female genital tract and lower urinary tract \nshare a  common embryonic origin, both arising from \nthe urogenital sinus. As estrogen plays an important \nrole in the function of the lower urinary tract through-\nout the premenopausal period, estrogen deficiency af-\nter menopause causes lower urinary tract symptoms, \nsuch as dysuria, urgency, frequency, nocturia, urinary \nincontinence (UI), and urinary tract infection (UTI) [74]. \nAccording to various sources, UI is present in 30–60% \nof perimenopausal and postmenopausal women [75].\nIrrespective of the volume, any kind of involuntary \nurination is defined as UI [76]. In particular, urge UI is \nmore prevalent after menopause than before, and its \nprevalence increases with time in women with estrogen \ndeficiency [77]. Early detection and individually tailored \npharmacologic (e.g., estrogen therapy, selective estrogen \nreceptor modulator, synthetic steroid, oxytocin, and \nDHEA) and/or nonpharmacologic (e.g., laser therapies, \nmoisturizers and lubricants, homeopathic remedies, and \nlifestyle modifications) treatment is cardinal for not only \nimproving quality of life but also for preventing exacer-\nbation of symptoms in women with this condition [78].\nAll guidelines recommend a  trial of conservative \ntreatment before invasive therapy. These conservative \ntherapies include behavioral therapy, physical therapy, \nand scheduled voiding as well as smoking cessation \n(smoking has been linked with an increase in estrogen \nmetabolism leading to vaginal atrophy [79]) and caf-\nfeine abstinence. The European Association of Urology \n(EAU) clarifies that caffeine reduction (Level 2 evidence) \nimproves urgency and frequency, but not UI [80, 81].\nThe EAU supports the use of containment devices \nand recommends disposable pads for light UI (Grade \nA), and pads, external devices, and catheters for mod-\nerate-to-severe UI (Grade A), with attention paid to bal-\nancing benefits and harms of each [81, 82].\nIn obese women, the Canadian Urological Associa-\ntion gives a Grade A recommendation for weight loss as \nan intervention, and the EAU recommends > 5% weight \nloss as a treatment plan (Grade A) [81, 83].\nThe incidence of UTI rises dramatically in elderly \nwomen. Studies have shown that 15 to 20% of women \naged 65 to 70 and 20 to 50% of women aged > 80 have \nbacteriuria [84]. In the low-estrogen state, the normally \npredominant lactobacilli diminish due to decreased \nvaginal-epithelial glycogen. Lactobacilli, via anaerobic \nmetabolism of glycogen, normally produce lactic acid and \nhydrogen peroxide. These are both essential in maintain-\ning an acidic and hostile vaginal environment to  E. coli \nand other potentially uropathogenic organisms [85].\n UI, anatomic changes such as a cystocele, increased \nresidual urine and diabetes are the risk factors for re-\ncurrent UTI in older women [86]. Lack of awareness of \nthe association between recurrent UTIs and GSM may \nresult in multiple unnecessary courses of antibiotic \ntherapy, antibiotic prophylaxis, and altered patterns of \nantimicrobial drug resistance [86].\nPelvic floor prolapse\nPelvic floor dysfunction is defined as abnormal func-\ntion of the pelvic floor and includes conditions that can \nhave significant adverse impacts on a woman’s quality \nof life, including UI (stress, urge, and mixed), fecal in-\ncontinence, pelvic organ prolapse, sexual dysfunction, \ndiastasis recti abdominis, pelvic girdle pain, and chronic \npain syndromes [87].\nPelvic organ prolapse (POP) is a hernia of the vag-\ninal wall. Elements of vaginal hanging and perineum \nsupport undergo mechanical strains that lead to this \npelvic floor disorder. The utero-sacral ligaments and the \narcus tendineus of the pelvic fascia lose their elasticity. \nAtrophic levator ani muscles no longer provide elastic, \nactive support. That is related to the aging of these \n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n94\nstructures but also to excessive mechanical strains – \npregnancy, delivery, dyschezia, physical practices. More-\nover, postural disorders lead to a direct orientation of \nthese strains on the genital slit [88].\nTreatment should address the degree of discomfort \nand function limitation the patient is experiencing and \nany associated urinary or fecal incontinence. Asymp-\ntomatic patients do not require treatment unless ulcer-\nation becomes a problem. \nTreatments include surgery, mechanical devices, \nand conservative management. Conservative manage-\nment approaches, such as providing lifestyle advice and \npelvic floor muscle training, are often used in cases of \nmild to moderate prolapse [89].\nSurgical intervention remains the definitive treat-\nment option for patients with symptomatic POP or \nstress urinary incontinence (SUI). In a  large popula-\ntion-based study in the United States, the lifetime risk \nof any primary surgery for SUI or POP reaches 20% in \nwomen aged 80 years [90, 91].\nVasomotor symptoms\nExtended use of menopause hormone therapy\nInitiating systemic menopause hormone therapy \n(MHT) in women older than 60 years in general is not \nrecommended. Discontinuation is typically suggested \nafter 5 years or by the age of 60. However, up to 8% \nof women continue to have hot flashes for 20 years or \nmore after menopause [92]. A study of women’s health \nacross the nation (SWAN) revealed that African American \nwomen have the longest median duration of vasomo-\ntor symptoms, at 10.1 years, and Japanese and Chinese \nAmerican women have the shortest, at 4.8 and 5.4 \nyears, respectively [93].\nThe NAMS guideline from 2017 suggested that the \nrecommendation to routinely discontinue systemic \nMHT after age 65 is not supported by data [94].\n Although the American Geriatrics Society has is-\nsued warnings against the use of MHT in women over \n65 years of age [95] two societies, the American Col-\nlege of Obstetricians and Gynecologists and the NAMS, \nsuggest that the decision to continue or stop hormone \ntherapy should include assessment of its risks and ben-\nefits, which may include relief from hot flashes, protec-\ntion against bone loss, and preservation of quality of \nlife [94,96]. The risks of MHT increase with age and du-\nration of use and appear to be less marked in patients \nwho take estrogen alone [96, 97].\nDiscontinuation of menopause hormone therapy\nControversy exists regarding how long MHT can be \nsafely administered and when it should be discontin-\nued [98]. Vasomotor symptoms (VMS) return in approx-\nimately 50% of women after discontinuation of hor -\nmone therapy, but data are lacking to directly compare \nthe effects of abrupt discontinuation with those taper-\ning over 3 to 6 months [99]. For recurrent, bothersome \nhot flashes, clinical experience supports a gradual taper, \nover 6 months to 1 year. However, protection against \nosteoporosis is lost rapidly with discontinuation [100]. \nReturn of estrogen deficiency symptoms is com-\nmon. In women who have recurrent VMS after stopping \ntherapy, there is no reliable way to determine whether \nthe symptoms will resolve quickly or persist for a pro-\nlonged time. For women who experience recurrent, \nbothersome hot flashes after stopping estrogen, Martin \nand Barbieri suggest initially nonhormonal options be-\nfore considering resuming estrogen [101].\nTo summarize, after 3 to 5 years of menopause hor-\nmone therapy, there should be an attempt to taper and \neventually discontinue treatment. If symptoms persist, \nlower doses or transdermal therapy could be offered, \nwith periodic reevaluation of the risks and benefits. If \nvaginal moisturizers and lubricants are not sufficient \nfor genitourinary symptoms after discontinuation of \ntreatment, low-dose vaginal hormone therapy can be \noffered [98].\nNon-hormonal therapy\nFor women complaining about VMS, menopaus-\nal hormone therapy (MHT) is recognized as the first-\nline therapy [102]; however, alternative treatments are \nneeded in case of a contraindication to MHT, adverse \nside effects, and poor compliance [103]. Additionally, \nthere are also women who refuse hormonal treatment \nfor a variety of reasons, mainly due to their fear of in-\ncreasing the risk of cancer or weight gain [104, 105]. \nHence, it is necessary to search for nonhormonal treat-\nments that could be beneficial to women. \nParoxetine is an antidepressant drug which be-\nlongs to the SSRI (selective serotonin reuptake inhib-\nitors) class. SSRIs such as citalopram or escitalopram \nwere the first to be described as effective in reducing \nVMS severity [106]. In 2013, the United States Food and \nDrug Administration (US FDA) approved the use of low-\ndose paroxetine for the management of hot flushes \nand night sweats. In a systemic review from 2019 the \nauthors concluded that low-dosage paroxetine can be \nuseful in reducing VMS such as hot flushes in physi-\nological or surgical postmenopausal women. However, \nadditional studies are required to assess the efficacy of \nparoxetine on sleep disturbance [107].\nAs mentioned earlier, sleep disturbances increase \naround menopause, impacting the quality of life. When \nhormone replacement therapy is contraindicated, it is \nnecessary to provide alternative treatments [108].\nDe Franciscis et al. in their study aimed to observe \nthe effects of an herbal remedy from pollen extracts \n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n95\nand soy isoflavones for menopausal complaints, partic-\nularly on sleep disorders. The authors concluded that \nnon-hormonal treatments can effectively be used in \nsymptomatic menopausal women: among these, after \nsix months of treatment, pollen extracts might achieve \na better improvement of hot flushes, sleep disturbanc-\nes and menopause-related symptoms than soy isofla-\nvones. The herbal remedy from pollen extracts is mainly \neffective when the quality of sleep is the most disturb-\ning complaint [108].\nIn a  recent review paper Genazzani et al. focused \non a  purified and specific cytoplasmic pollen extract, \nPureCyTonin, and its beneficial effects in the treatment \nof menopausal symptoms (e.g. hot flushes) in healthy \nwomen [109].\nPureCyTonin is the main ingredient of the food sup-\nplement Serelys, which is a  combination of purified \npollen/pistil cytoplasmic extracts. The pollen and pistils \ncome from selected plants belonging to the Gramineae \nfamily and/or Pinaceae family and are harvested sepa-\nrately using a standardized method [109].\nGenazzani et al. concluded that Serelys is an effective \nand safe non-hormonal alternative for alleviating meno-\npausal symptoms without increasing the risk of breast \ncancer in women in whom MHT is contraindicated or \nwho do not wish to use hormones. Serelys has proven \nto be safe and efficacious. It improves hot flushes, sleep \ndisturbances, and nervousness in menopausal women. \nThese findings seem to correlate with the effect of its \nmain ingredient, PureCyTonin, on inhibition of the re-\nuptake of serotonin and other neurotransmitters [109].\nIsoflavones are a group of naturally occurring com-\npounds found in fruits, grains, and vegetables that are \nstructurally similar to estrogen and have an affinity for \nestrogen receptors. These chemicals have been shown \nto elicit both estrogen-agonistic and estrogen-antago-\nnistic properties when ingested orally in large quanti-\nties [110, 111].\nTwo specific dietary isoflavones, genistein and daid-\nzein, are found in high concentrations in legumes such \nas soy, chickpeas, lentils, and red clover. Initial inter -\nest in these compounds for the management of VMS \nstemmed from the observation that Asian women, who \ntraditionally consume large quantities of soy in their \ndiet, appear to have lower rates of menopausal symp-\ntoms [110, 112].\nA 2013 Cochrane meta-analysis was performed on \n43 randomized, controlled studies of 4,084 patients to \nassess the efficacy and safety of food products, extracts, \nand supplements containing high levels of phytoestro-\ngens in the amelioration of VMS in perimenopausal \nand postmenopausal women. The authors summarized \nthat no conclusive evidence shows that phytoestrogen \nsupplements effectively reduce the frequency or sever-\nity of hot flushes and night sweats in perimenopausal \nor postmenopausal women, although benefits derived \nfrom concentrates of genistein should be further inves-\ntigated [110].\nVarious supplements that have been used in the \nmanagement of VMS include  Dioscorea villosa or wild \nyams, evening primrose, dong quai, American ginseng, \nkava kava, and St. John’s wort. The evidence from clin-\nical trials demonstrating benefit is conflicting and lim-\nited [111, 113, 114]. Therefore, current guidelines do not \nsupport the use of such agents at this time [111]. \nThere has been a lot of conflicting information with \nregards to black cohosh, scientific name  Actaea race-\nmosa L (previously  Cimicifugae racemosae),which has \nbeen used by Native Americans to treat malaria, im-\npaired kidney function, sore throat, rheumatism, mal-\naise, and menstrual irregularities [115]. The rhizome of \nblack cohosh contains a number of biologically active \nconstituents (including the triterpene glycosides actein \nand cimicifugoside, as well as fatty acids, resins, caffe-\nic acids, isoferulic acids and isoflavones) [116], but the \nmechanism of action is unclear [111].\nA 2012 Cochrane review [117] analyzed 16 random-\nized controlled trials of 2,027 perimenopausal or post-\nmenopausal women treated with black cohosh using \na median daily dose of 40 mg for a mean duration of \n23 weeks. There was no significant difference between \nblack cohosh and placebo in the frequency of hot flash-\nes. Data on safety were also inconclusive. The authors \nconcluded that, at that time, there was insufficient ev-\nidence to support the use of black cohosh for meno-\npausal symptoms. Black cohosh appears to have no \neffect on circulating luteinizing hormone, follicle-stim-\nulating hormone, prolactin, or estradiol. A  52-week \nstudy reassuringly demonstrated that black cohosh \ndoes not increase endometrial thickness on ultrasound \n[118]. Reports of possible hepatotoxicity started to ap-\npear after 2000; however, after examining all report-\ned cases, the US Pharmacopeial Convention’s Dietary \nSupplements-Botanicals Expert Committee found only \n30 reports possibly related to black cohosh. Eventual-\nly, the committee issued a directive that black cohosh \nproducts carry a  warning statement: Discontinue use \nand consult a healthcare practitioner if you have a liver \ndisorder or develop symptoms of liver trouble, such as \nabdominal pain, dark urine, or jaundice [111].\nAdditionally, the NAMS in the 2015 position state-\nment on nonhormonal management of menopause \nstated that there are negative, insufficient, or inconclu-\nsive data suggesting that the following should not be \nrecommended as proven therapies for managing VMS: \ncooling techniques, avoidance of triggers, exercise, yoga, \npaced respiration, relaxation, over-the-counter supple-\nments and herbal therapies, acupuncture, calibration of \nneural oscillations, and chiropractic interventions [111]. \nAlthough there are many health benefits associated with \nthe aforementioned therapies, attempts to use them are \nlikely to delay receipt of more appropriate and effective \n\nMenopause Review/Przegląd Menopauzalny 20(2) 2021\n96\ntherapies. In symptomatic women, such delays should \nbe avoided given the association of VMS with other \nsymptoms and overall quality of life [111].\n Incorporating the available evidence into clini-\ncal practice will help ensure that women receive evi-\ndence-based recommendations along with appropriate \ncautions for appropriate and timely management of \nVMS [111].\nConclusions\nGynecologists can have a significant impact on the \nhealth of the elderly female patient as specialists and \nprimary care physicians. Nowadays, most women spend \nmore than one-third of their lives after menopause [92]. \nTherefore, there is plenty of opportunity for gynecolo-\ngists to cater to the needs of postmenopausal women. \nDisclosure\nThe authors report no conflict of interest.\nReferences\n1. Broker SA, Venugopalan PP , Bhat SN. Study of menopausal symptoms, \nand perceptions about menopause among women at a rural community \nin Kerala. J Midlife Health 2013; 4: 182-187.\n2. 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