Postmenopausal women in gynecological care

Menopause is defined as the last menstrual period followed by no menstruation for the next 12 months with no pathological causes of such a condition identified. Menopause is one of the most important events in the female reproductive life cycle, a tran- sition from the reproductive to the nonreproductive stage. This introduces several physiological changes that affect a woman’s further life permanently, set- ting the stage for aging [1, 2]. In the United States, the median age at which menopause occurs is 52, but it can vary between 40 and 58 years of age [3]. The mean age of the onset of natural menopause in Polish population is 51.25 [4]. Over the last 25 years, a slowdown in de- mographic development in Poland and significant changes in the age structure of its inhabitants have been observed. At the end of 2014, the population of Poland reached 38.5 million, including over 8.5 mil- lion people aged 60 and above (over 22%). Among the elderly population, the majority are women (59%). Life expectancy for people aged 60 has also increased over the past 23 years. The life expectancy of 60-year-olds has extended by 4.1 years for men Postmenopausal women in gynecological care Magdalena Pertyńska-Marczewska1, Tomasz Pertyński2 1Private Practice, London, United Kingdom 2Faculty of Health Science, Mazovian Public University in Plock, Poland

Menopause is one of the most important events in the female reproductive life cycle, being a transition from the reproductive to the nonreproductive stage. It is a milestone that may have a negative influence on quality of life and one that brings in several physiological changes that affect the life of a woman permanently. According to a Polish epidemiological forecast, in 2050 the average female life expectancy will be 87.5, which is 6.4 years longer than today. Thus, the life expectancy of women who will be 60 or older in 2050 will also extend. Therefore, strategies need to be optimized to maintain postreproductive health, in part because of increased longevity. The general gynecologist can expect to see more elderly female patients as the popula- tion continues to age. Office management of the gynecologic problems of geriatric women requires sensi- tivity to the special needs of this group. Nowadays, most women spend more than one-third of their lives after menopause; therefore there is plenty of opportunity for gynecologists to cater to the needs of post- menopausal women. It is in their scope of practice to help postmenopausal women through “healthy aging”. In this review we look into screenings, early identification, lifestyle modifications and appropriate intervention that may prevent many chronic conditions that cause morbidity and mortality during the postmenopausal years. Key words: postmenopause, screening, healthy aging. and 4.5 for women since 1991. According to an ep- idemiological forecast, in 2050 the average female life expectancy will be 87.5, which is 6.4 years longer than today. Thus, the life expectancy of people who will be 60 or older in 2050 will also extend [5]. A report by the Population Reference Bureau es- timated that 40 million people in the U.S. are 65 or older – a number that is expected to reach 89 mil- lion by 2050 [6] – and by the year 2025, the number of postmenopausal women is expected to rise to 1.1 billion worldwide [7]. These changing demograph- ics raise the problem of providing gynecologic care for these women and the issue of the role of the gy- necologist as their primary care physician [8], since as experts in women’s health care, gynecologists are uniquely trained to guide, counsel, diagnose, and treat women across their entire lifetime [9]. It is in their scope of practice to help postmenopaus- al women through “healthy aging”. Healthy aging includes survival to old age, delay of the onset of non-communicable diseases and op- timal functioning for a maximal period at individual levels of cells and body systems [7]. An annual “well-woman” visit provides an excel- lent opportunity to counsel patients about maintain- Corresponding author: dr n med. Magdalena Pertyńska-Marczewska, e-mail: [email protected] Submitted: 22.02.2021 Accepted: 28.04.2021 Menopause Review/Przegląd Menopauzalny 20(2) 2021 89 ing a  healthy lifestyle and minimizing health risks. The periodic well-woman care visit should include screening, evaluation, and counseling [9]. Preventive care recommendations Screenings, early identification, lifestyle modifi- cations and appropriate intervention may prevent many chronic conditions that cause morbidity and mortality during the postmenopausal years [10]. Osteoporosis screening Osteoporosis is characterized by low bone mass, structural deterioration, and porous bone, which are associated with higher fracture risk [11]. Bone loss, related to declining estrogen levels, increases frac- ture risk in postmenopausal women, who make up the majority of osteoporosis cases [12]. For example, the aging U.S. population is predicted to contribute to as much as a 50% increase in prevalence by 2025 [13]. Therefore, early detection and treatment of high-risk patients with antiresorptive medications [11], and optimization of bone health throughout life can help prevent osteoporosis. Worldwide, osteoporosis causes more than 9 million fractures a  year, meaning there is a  fragility fracture every 3 s [14]. In just the 6 largest European countries the total number of fragility fractures is estimated to increase from 2.7 million in 2017 to 3.3 million in 2030, an increase of 23.3% [15]. About one-tenth of women in their 60s, one-fifth of women in their 70s, two-fifths of women in their 80s and two-thirds of women in their 90s have osteoporosis and an increased risk of fragility fracture [16]. In the general Polish population, over 2 million peo- ple over the age of 50 (every third woman and every fifth man) suffer from osteoporosis, in the majority of the cases, complicated by fracture [17]. It is important to remember that fractures at the hip and vertebrae are among the most common and seri- ous sites of osteoporotic fracture. Fragility fractures of the humerus, forearm, ribs, tibia (in women, but not in- cluding ankle fractures), pelvis and other femoral frac- tures after the age of 50 are fractures associated with low BMD [18]. Created in 1984, the U.S. Preventive Services Task Force (USPSTF) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clini- cal preventive services such as screenings, counseling services, or preventive medications. Guidelines from the USPSTF recommend screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures. Diagnostic and treatment criteria for osteoporosis rely on hip and lumbar spine dual-energy X-ray absorp- tiometry measurements (DXA). The guidelines state that dual-energy X-ray absorptiometry screening is recommended for women 65 years and older, and the USPSTF endorsed use of the Fracture Risk Assessment Tool FRAX to identify screening candidates among younger postmenopausal women aged 50 to 64 years. The recommended threshold score is 9.3% [19, 20]. DXA provides measurement of bone mineral density (BMD), and most treatment guidelines use central DXA to define osteoporosis and the threshold at which to start drug therapies to prevent osteoporotic fractures. The major change in the current recommendation is that the USPSTF expanded its consideration of ev- idence related to fracture risk assessment, with or without BMD testing [20]. For women 65 and older, the USPSTF found convincing evidence that screening can detect osteoporosis and that treatment of women with osteoporosis can provide at least a  moderate benefit in preventing fractures. For postmenopausal women younger than 65 who are at increased risk of osteopo- rosis, the USPSTF found adequate evidence that screen- ing can detect osteoporosis and that treatment pro- vides a moderate benefit in preventing fractures [20]. In addition to adequate calcium and vitamin D in- take and weight-bearing exercise, multiple drug ther - apies are approved to reduce fracture risk, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen [20]. According to the USPSTF , effective fall prevention measures include weight-bearing exer - cise and balance training three times per week, mus- cle strengthening twice per week, and 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity. With a  re- vised scope of review, as well as newer evidence from trials reporting no benefit, the USPSTF found that vita- min D supplementation has no benefit in fall prevention in community-dwelling older adults not known to have vitamin D deficiency or insufficiency. Thus, the USPSTF now recommends against vitamin D supplementation for the prevention of falls in community-dwelling older adults [20]. However, The National Institute on Aging recommends vitamin D supplementation of at least 800 IU per day for persons with vitamin D deficiency or who are at increased risk for falls [21]. Cardiovascular disease screening Cardiovascular disease (CVD) is the leading cause of death and disability in women older than 50, exceeding the number of deaths from malignant neoplasms, dia- betes mellitus, and chronic lower respiratory diseases combined [22]. The prevalence of CVD increases rapidly at the onset of menopause and continues to increase through the post-menopausal period [10]. Menopause Review/Przegląd Menopauzalny 20(2) 2021 90 Periodic cardiovascular risk assessment in post- menopausal women can identify risk factors and enable implementation of risk reduction strategies [10, 23]. The 2019 American College of Cardiology/American Heart Association (ACC/AHA) guideline recommends using the pooled cohort risk assessment equations (http:// tools.acc.org/ASCVD-Risk-Estimator/) every three to five years to calculate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD), including myocardial infarction and stroke [24]. Since 2008 the USPSTF has strongly recommended routinely screening women 45 and older for lipid disor- ders and treating abnormal lipid levels in persons who are at increased risk of coronary heart disease (CHD). Screening for diabetes with fasting plasma glucose is indicated for women with risk factors for CHD, such as hypertension and hyperlipidemia [25].  The ACC/AHA recommend that all adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish, and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages. For over - weight and obese adults, counseling and caloric restric- tion are recommended for achieving and maintaining weight loss [24]. In 2015 the USPSTF issued an update to the 2008 recommendation statement in which the USPSTF rec- ommended screening for diabetes in asymptomatic adults with hypertension (defined as sustained blood pressure of > 135/80 mm Hg). New evidence led the USPSTF to conclude that there is a moderate net bene- fit to measuring blood glucose in adults who are at in- creased risk for diabetes [26]. Additionally, data suggest that smoking cessation after an MI and treatment of hypertension and hyperlipidemia lower the risk for CHD events in women [27]. The USPSTF and ACC/AHA recommend aspirin and statins for primary prevention of CVD in selected high- risk patients who are at low risk of adverse effects from these medications [28, 29]. Cancer screening Breast cancer There is consistency across multiple organization- al guidelines that average-risk women benefit from screening mammography at least every other year from 50 to 74 years of age [30]. The evidence that screening reduces mortality from breast cancer is strongest for women 50 to 69 years of age. There is no evidence of benefit for women older than 75 years, but the USPSTF recommends screening women older than 70 years who have a reasonable life expectancy [31]. The USPSTF concludes that while there are risks as- sociated with mammography, the benefit of screening mammography outweighs the harms by at least a mod- erate amount from age 50 to 74 years and especially for women in their 60s. For women in their 40s, the benefits still outweigh the harms, but to a smaller degree; this balance may therefore be more subject to individual values and preferences than it is for older women [32]. On the other hand, the American Cancer Society recom- mends performing mammography annually in women 45 to 54 years of age, biennially in women 55 years and older, and to not screen women with a life expectancy of less than 10 years [30]. Additionally, the American College of Obstetricians and Gynecologists recommends a  mammography an- nually beginning at 40 years of age [33]. In recent years, a newer type of mammogram called digital breast tomosynthesis (commonly known as three-dimensional [3D] mammography) has become much more common, although it is not available in all breast imaging centers. Many studies have found that 3D mammography appears to reduce the likelihood of be- ing called back for follow-up testing. It also appears to re- veal more breast cancers, and several studies have shown that it can be helpful for women with denser breasts [34]. The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for ad- verse medication effects [35]. Based on expert opinion, the American Cancer Society and the National Compre- hensive Cancer Network include aromatase inhibitors, exemestane, or anastrozole as additional options [36]. In Poland, breast cancer is the most common ma- lignancy in women (17 379 cases in 2014; standardized incidence rate 51.6/100,000 [37]) and the second cause of death due to cancer among Polish women [37]. The recommendations of the Polish Gynecological Society (23.2.2005) state that every woman between 45 and 50 year of age should have a  mammography performed every 2 years. From the age of 50 the mam- mography should be performed annually. Additionally, the experts pointed out that the breast ultrasound is not an examination that replaces mammography but is a supplementary part of the diagnostic process. Cervical cancer In the elderly population, cancer is one of the pre- dominant causes of mortality and morbidity, and its in- cidence increases with ageing. Sixty percent of all can- cers and 70% of cancer-related deaths occur in patients aged 65 years and over [38]. In patients aged 65 and over, cervical cancer has mortality rates ranging between 40 and 50%. However, there is evidence that regular screening reduces cer - vical cancer risk at a rate of 80% and early detection through routine Papanicolaou (Pap) testing and treat- ment of precursor cervical intraepithelial neoplasia can lower mortality from cervical cancer [39, 40]. Menopause Review/Przegląd Menopauzalny 20(2) 2021 91 According to American Cancer Society recommen- dations, screening tests for cervical cancer should be initiated within the first 3 years from the first sexual in- tercourse or at most at the age of 21. Every year obstetric examination and a Pap smear test should be performed. If the last successive 3 screening test results are within normal limits, then screening tests can be done every 2–3 years. Postmenopausal women should receive hu- man papillomavirus and cytology co-testing every five years, or cytology alone every three years, until the age of 65 years [41]. If the last 2 tests yield negative results, screening should be stopped when the patient reaches 65 years of age. Once screening has stopped, it should not resume in women older than 65 years, even if they report having a new sexual partner [42]. Screening should be discontinued in women who undergo total hysterectomy for benign disease [42].  Additionally, shared guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and the American Society for Clin- ical Pathology (ACS/ASCCP/ASCP) state that routine screening should continue for at least 20 years after spontaneous regression or appropriate management of a  precancerous lesion, even if this extends screening past age 65 years. In 2018, the USPSTF updated its screening guide- lines [42]. In addition to continuing to recommend tri- ennial cytology (Papanicolaou tests) for women aged 21 to 29 years followed by either continued triennial cytology or adding a test for high-risk types of HPV ev- ery 5 years from ages 30 to 65 years, the USPSTF en- dorsed a strategy of hrHPV testing alone every 5 years for women aged 30 to 65 years. The USPSTF stated that referring all women with abnormal test results directly for colposcopy would lead to a  much greater number of colposcopies, but it did not recommend any particu- lar triage strategy for women with a positive test result for hrHPV; the Society of Gynecologic Oncology rec- ommends triaging these women with HPV genotyping (tests for HPV types 16 or 18) [43]. Endometrial cancer and intrauterine pathologies Endometrial cancer is the most common gynecolog- ic cancer in developed countries and accounts for nearly 5% of cancer cases and more than 2% of deaths due to cancer in women worldwide [44]. Between 4 and 11% of postmenopausal women will experience postmenopausal bleeding (PMB) [45], ac- counting for approximately two-thirds of all gynecolog- ic visits among perimenopausal and postmenopausal women [46]. However, the risk of endometrial cancer in women with PMB varies widely in individual studies from 3 to 25% [47]. The most common causes of uterine bleeding in postmenopausal women are benign and include vagi- nal or endometrial atrophy, cervical polyps, and submu- cosal fibroids [45]. In many European countries, guidelines recom- mend transvaginal ultrasound (TVUS) as the first-line approach in evaluation of postmenopausal bleeding, with histologic assessment indicated for women with a  thickened endometrium based on cutoffs ranging from 3 to 5 mm [46, 48]. In the United States, evaluation of PMB begins with a screening TVUS [49]. Findings of an endometrium of ≤ 4 mm on TVUS indicate a low likelihood of the pres- ence of endometrial cancer, and treatment for atrophy or changes to the hormone replacement therapy regi- men constitute reasonable first-line management; en- dometrial biopsy is not recommended [50]. However, because rare cases of endometrial car - cinoma (particularly type II) can present with an en- dometrial thickness of less than 3 mm, persistent or recurrent uterine bleeding should prompt a histologic evaluation of the endometrium regardless of endome- trial thickness [49]. For patients with persistent PMB or thickened en- dometrium ≥ 4 mm on TVUS, biopsy sampling of the endometrium should be performed. A negative tissue biopsy result in women with PMB is not considered to be an endpoint, and further evalu- ation with hysteroscopy to evaluate for focal disease is imperative. The results of endometrial biopsy are only an endpoint to the evaluation of PMB when atypical hyperplasia or endometrial cancer is identified [49, 50]. Hysteroscopy is confirmed as the gold standard in the assessment of abnormal uterine bleeding in meno- pause, permitting the elimination of false-negative re- sults of blind biopsy through direct visualization of the uterine cavity and the performance of targeted biopsy in case of doubt [51]. It permits full visualization of the endocervix, endometrial cavity and tubal ostia, allow- ing visual diagnosis of focal endometrial lesions that are missed with endometrial sampling, TVS or saline infusion sonohysterography [51]. Two  types of the procedure are generally per - formed: diagnostic and operative hysteroscopy. Diag- nostic hysteroscopy allows visualization of the endo- cervical canal, endometrial cavity, and fallopian tube ostia. Operative hysteroscopy incorporates the use of mechanical, electrosurgical, or laser instruments to treat intracavitary pathology, thus offering a “see-and- treat” approach [52]. Advances in technology have led to miniaturization of high-definition hysteroscopes without compromis- ing optical performance, thereby making hysteroscopy a simple, safe and well-tolerated office procedure. The new surgical technology such as bipolar electrosurgery, endometrial ablation devices, hysteroscopic steriliza- tion, and morcellators has revolutionized this surgical modality [53]. The modern development of hysterosco- py transformed the approach to intrauterine patholo- gies from a blind procedure under general anesthesia Menopause Review/Przegląd Menopauzalny 20(2) 2021 92 to an outpatient procedure performed under direct visualization, offering a  comprehensive diagnosis and management approach [45]. Colorectal cancer The stage at which colorectal cancer is detected has a substantial effect on survival. The five-year survival rate is approximately 91% with localized disease but drops to 6% among individuals presenting with distant metastasis [54]. Colorectal cancer has a male predominance and is strongly associated with age; 80% of new cases occur in patients aged over 60. Obesity and limited exercise are strong risk factors. Diets low in fruit and vegetables and fiber and high in red meat have also been associated with an increased risk. Patients with one first-degree relative under 45 or two first-degree relatives of any age who developed colorectal cancer have an approximate lifetime risk of developing the disease of 16–25% in men and 10–15% in women. Having one first-degree relative who developed the disease after the age of 65 barely increases lifetime risk. Patients with ulcerative colitis and Crohn’s colitis also have an increased lifetime risk of colorectal cancer [55]. The American Cancer Society 2018 guideline for colorectal cancer screening recommends that aver - age-risk adults aged 45 years and older undergo regu- lar screening with either a high-sensitivity stool-based test or a structural (visual) examination, based on per - sonal preferences and test availability. As a part of the screening process, all positive results on non-colonos- copy screening tests should be followed up with timely colonoscopy [56]. The USPSTF recommends screening for colorectal cancer beginning at 50 years of age and continuing through 75, then individualized decision making in pa- tients 76 to 85 years of age [57]. High-risk women who may require more intensive screening and/or genetic testing include those with a history of genetic disorders (e.g., familial adenomatous polyposis), inflammatory bowel disease, or a previous adenomatous polyp or col- orectal cancer [57]. Sexually transmitted diseases screening Older women are often sexually active, but physi- cians caring for older women rarely address sexual con- cerns. Although women’s desire for sex declines with age, a majority of older women rate sex as having im- portance in their lives [58]. For example, in England, approximately 7% of new sexually transmitted disease (STD) diagnoses in 2018 were among individuals aged 45–64 years [59]. Accord- ing to American data from 2005, an estimated 65% of women 51 to 64 years of age engage in sexual inter - course at least once per week [60]. In a brand new British paper [61] the authors stat- ed that the identified barriers to STD risk prevention among midlife adults include low knowledge about STDs, prioritization of intimacy above STD risks in new relationships, [62] stigmatization of STDs among older adults [62], and reduced motivation to consider safer sex following removal of pregnancy risk due to meno- pause or permanent contraception [63]. Interestingly, one American study found that 1% of widowed women 67 to 99 years of age developed an STD during a nine- year study [64]. The USPSTF recommends that high-risk sexually ac- tive women receive intensive behavioral counseling to reduce STD risk, and annual screening for chlamydia, gonorrhea, syphilis, and human immunodeficiency vi- rus (HIV) infection [65]. Genitourinary syndrome The genitourinary syndrome of menopause (GSM) is a  term that describes various menopausal symp- toms and signs including not only genital symptoms (dryness, burning, and irritation) and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function) but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections) [66]. A majority of women suffering from GSM are of old- er age, with 50–70% of postmenopausal women being symptomatic at least to some degree [67]. Unlike other menopausal symptoms, GSM is a chron- ic, progressive condition of the vulvovaginal and lower urinary tract [68]. According to the newest statement from the North American Menopause Society (NAMS), GMS affects approximately 27 to 84% of postmenopaus- al women and can significantly impair health, sexual function, and quality of life [69]. These symptoms are directly related to the reduced circulating estrogen levels after menopause. Estrogen receptors (ERs; both α and α) are present in the vagina, vulva, musculature of the pelvic floor, endopelvic fascia, urethra, and bladder trigone during reproductive life; their levels decline with menopause and may be re- stored by estrogen treatment [70]. As a result of estro- gen deficiency after menopause, anatomic and histo- logic changes occur in female genital tissues, including reduction in the content of collagen and hyaluronic acid and in the levels of elastin, thinning of the epithelium, alterations in the function of smooth muscle cells, in- crease in the density of connective tissue, and fewer blood vessels. These changes reduce elasticity of the vagina, increase vaginal pH, lead to changes in vaginal flora, diminish lubrication, and increase vulnerability to physical irritation and trauma [70]. The NAMS noted that GSM is likely underdiagnosed and undertreated, but in most cases, symptoms can be effectively managed. The diagnosis and evaluation Menopause Review/Przegląd Menopauzalny 20(2) 2021 93 of GSM are clinical and  mostly established through a thorough medical history and physical pelvic exam- ination [71]. Additionally, two instruments of measurement prop- erties of patient-reported outcome measures specific for genitourinary symptoms (the Vulvovaginal Symp- toms Questionnaire and the Day-to-Day Impact of Vag- inal Aging (DIVA) Questionnaire) have been shown to be valid after a thorough assessment. These two tools can be efficiently used for the evaluation of GSM symp- toms and measurement of their impact on the QOL of patients [72, 73]. A number of over-the-counter and government-ap- proved prescription therapies available in the United States and Canada demonstrate diverse effectiveness, depending on the severity of symptoms. These include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hor - mone therapy, and the estrogen agonist/antagonist os- pemifene. Low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are effec- tive treatments for moderate to severe GSM. When low-dose vaginal estrogen or DHEA or ospemifene is administered, a progestogen is not indicated; however, endometrial safety has not been studied in clinical tri- als beyond 1 year. There are insufficient data at present to confirm the safety of vaginal estrogen or DHEA or ospemifene in women with breast cancer; management of GSM should consider the woman’s needs and the recommendations of her oncologist [69]. Additionally, because of the insufficient number of placebo-controlled trials of energy-based therapies, including laser, the NAMS cannot draw conclusions on efficacy and safety or make treatment recommenda- tions [69]. Urinary incontinence and urinary tract infections The female genital tract and lower urinary tract share a  common embryonic origin, both arising from the urogenital sinus. As estrogen plays an important role in the function of the lower urinary tract through- out the premenopausal period, estrogen deficiency af- ter menopause causes lower urinary tract symptoms, such as dysuria, urgency, frequency, nocturia, urinary incontinence (UI), and urinary tract infection (UTI) [74]. According to various sources, UI is present in 30–60% of perimenopausal and postmenopausal women [75]. Irrespective of the volume, any kind of involuntary urination is defined as UI [76]. In particular, urge UI is more prevalent after menopause than before, and its prevalence increases with time in women with estrogen deficiency [77]. Early detection and individually tailored pharmacologic (e.g., estrogen therapy, selective estrogen receptor modulator, synthetic steroid, oxytocin, and DHEA) and/or nonpharmacologic (e.g., laser therapies, moisturizers and lubricants, homeopathic remedies, and lifestyle modifications) treatment is cardinal for not only improving quality of life but also for preventing exacer- bation of symptoms in women with this condition [78]. All guidelines recommend a  trial of conservative treatment before invasive therapy. These conservative therapies include behavioral therapy, physical therapy, and scheduled voiding as well as smoking cessation (smoking has been linked with an increase in estrogen metabolism leading to vaginal atrophy [79]) and caf- feine abstinence. The European Association of Urology (EAU) clarifies that caffeine reduction (Level 2 evidence) improves urgency and frequency, but not UI [80, 81]. The EAU supports the use of containment devices and recommends disposable pads for light UI (Grade A), and pads, external devices, and catheters for mod- erate-to-severe UI (Grade A), with attention paid to bal- ancing benefits and harms of each [81, 82]. In obese women, the Canadian Urological Associa- tion gives a Grade A recommendation for weight loss as an intervention, and the EAU recommends > 5% weight loss as a treatment plan (Grade A) [81, 83]. The incidence of UTI rises dramatically in elderly women. Studies have shown that 15 to 20% of women aged 65 to 70 and 20 to 50% of women aged > 80 have bacteriuria [84]. In the low-estrogen state, the normally predominant lactobacilli diminish due to decreased vaginal-epithelial glycogen. Lactobacilli, via anaerobic metabolism of glycogen, normally produce lactic acid and hydrogen peroxide. These are both essential in maintain- ing an acidic and hostile vaginal environment to  E. coli and other potentially uropathogenic organisms [85].  UI, anatomic changes such as a cystocele, increased residual urine and diabetes are the risk factors for re- current UTI in older women [86]. Lack of awareness of the association between recurrent UTIs and GSM may

in multiple unnecessary courses of antibiotic therapy, antibiotic prophylaxis, and altered patterns of antimicrobial drug resistance [86]. Pelvic floor prolapse Pelvic floor dysfunction is defined as abnormal func- tion of the pelvic floor and includes conditions that can have significant adverse impacts on a woman’s quality of life, including UI (stress, urge, and mixed), fecal in- continence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes [87]. Pelvic organ prolapse (POP) is a hernia of the vag- inal wall. Elements of vaginal hanging and perineum support undergo mechanical strains that lead to this pelvic floor disorder. The utero-sacral ligaments and the arcus tendineus of the pelvic fascia lose their elasticity. Atrophic levator ani muscles no longer provide elastic, active support. That is related to the aging of these Menopause Review/Przegląd Menopauzalny 20(2) 2021 94 structures but also to excessive mechanical strains – pregnancy, delivery, dyschezia, physical practices. More- over, postural disorders lead to a direct orientation of these strains on the genital slit [88]. Treatment should address the degree of discomfort and function limitation the patient is experiencing and any associated urinary or fecal incontinence. Asymp- tomatic patients do not require treatment unless ulcer- ation becomes a problem.  Treatments include surgery, mechanical devices, and conservative management. Conservative manage- ment approaches, such as providing lifestyle advice and pelvic floor muscle training, are often used in cases of mild to moderate prolapse [89]. Surgical intervention remains the definitive treat- ment option for patients with symptomatic POP or stress urinary incontinence (SUI). In a  large popula- tion-based study in the United States, the lifetime risk of any primary surgery for SUI or POP reaches 20% in women aged 80 years [90, 91]. Vasomotor symptoms Extended use of menopause hormone therapy Initiating systemic menopause hormone therapy (MHT) in women older than 60 years in general is not recommended. Discontinuation is typically suggested after 5 years or by the age of 60. However, up to 8% of women continue to have hot flashes for 20 years or more after menopause [92]. A study of women’s health across the nation (SWAN) revealed that African American women have the longest median duration of vasomo- tor symptoms, at 10.1 years, and Japanese and Chinese American women have the shortest, at 4.8 and 5.4 years, respectively [93]. The NAMS guideline from 2017 suggested that the recommendation to routinely discontinue systemic MHT after age 65 is not supported by data [94]. Although the American Geriatrics Society has is- sued warnings against the use of MHT in women over 65 years of age [95] two societies, the American Col- lege of Obstetricians and Gynecologists and the NAMS, suggest that the decision to continue or stop hormone therapy should include assessment of its risks and ben- efits, which may include relief from hot flashes, protec- tion against bone loss, and preservation of quality of life [94,96]. The risks of MHT increase with age and du- ration of use and appear to be less marked in patients who take estrogen alone [96, 97]. Discontinuation of menopause hormone therapy Controversy exists regarding how long MHT can be safely administered and when it should be discontin- ued [98]. Vasomotor symptoms (VMS) return in approx- imately 50% of women after discontinuation of hor - mone therapy, but data are lacking to directly compare the effects of abrupt discontinuation with those taper- ing over 3 to 6 months [99]. For recurrent, bothersome hot flashes, clinical experience supports a gradual taper, over 6 months to 1 year. However, protection against osteoporosis is lost rapidly with discontinuation [100]. Return of estrogen deficiency symptoms is com- mon. In women who have recurrent VMS after stopping therapy, there is no reliable way to determine whether the symptoms will resolve quickly or persist for a pro- longed time. For women who experience recurrent, bothersome hot flashes after stopping estrogen, Martin and Barbieri suggest initially nonhormonal options be- fore considering resuming estrogen [101]. To summarize, after 3 to 5 years of menopause hor- mone therapy, there should be an attempt to taper and eventually discontinue treatment. If symptoms persist, lower doses or transdermal therapy could be offered, with periodic reevaluation of the risks and benefits. If vaginal moisturizers and lubricants are not sufficient for genitourinary symptoms after discontinuation of treatment, low-dose vaginal hormone therapy can be offered [98]. Non-hormonal therapy For women complaining about VMS, menopaus- al hormone therapy (MHT) is recognized as the first- line therapy [102]; however, alternative treatments are needed in case of a contraindication to MHT, adverse side effects, and poor compliance [103]. Additionally, there are also women who refuse hormonal treatment for a variety of reasons, mainly due to their fear of in- creasing the risk of cancer or weight gain [104, 105]. Hence, it is necessary to search for nonhormonal treat- ments that could be beneficial to women. Paroxetine is an antidepressant drug which be- longs to the SSRI (selective serotonin reuptake inhib- itors) class. SSRIs such as citalopram or escitalopram were the first to be described as effective in reducing VMS severity [106]. In 2013, the United States Food and Drug Administration (US FDA) approved the use of low- dose paroxetine for the management of hot flushes and night sweats. In a systemic review from 2019 the authors concluded that low-dosage paroxetine can be useful in reducing VMS such as hot flushes in physi- ological or surgical postmenopausal women. However, additional studies are required to assess the efficacy of paroxetine on sleep disturbance [107]. As mentioned earlier, sleep disturbances increase around menopause, impacting the quality of life. When hormone replacement therapy is contraindicated, it is necessary to provide alternative treatments [108]. De Franciscis et al. in their study aimed to observe the effects of an herbal remedy from pollen extracts Menopause Review/Przegląd Menopauzalny 20(2) 2021 95 and soy isoflavones for menopausal complaints, partic- ularly on sleep disorders. The authors concluded that non-hormonal treatments can effectively be used in symptomatic menopausal women: among these, after six months of treatment, pollen extracts might achieve a better improvement of hot flushes, sleep disturbanc- es and menopause-related symptoms than soy isofla- vones. The herbal remedy from pollen extracts is mainly effective when the quality of sleep is the most disturb- ing complaint [108]. In a  recent review paper Genazzani et al. focused on a  purified and specific cytoplasmic pollen extract, PureCyTonin, and its beneficial effects in the treatment of menopausal symptoms (e.g. hot flushes) in healthy women [109]. PureCyTonin is the main ingredient of the food sup- plement Serelys, which is a  combination of purified pollen/pistil cytoplasmic extracts. The pollen and pistils come from selected plants belonging to the Gramineae family and/or Pinaceae family and are harvested sepa- rately using a standardized method [109]. Genazzani et al. concluded that Serelys is an effective and safe non-hormonal alternative for alleviating meno- pausal symptoms without increasing the risk of breast cancer in women in whom MHT is contraindicated or who do not wish to use hormones. Serelys has proven to be safe and efficacious. It improves hot flushes, sleep disturbances, and nervousness in menopausal women. These findings seem to correlate with the effect of its main ingredient, PureCyTonin, on inhibition of the re- uptake of serotonin and other neurotransmitters [109]. Isoflavones are a group of naturally occurring com- pounds found in fruits, grains, and vegetables that are structurally similar to estrogen and have an affinity for estrogen receptors. These chemicals have been shown to elicit both estrogen-agonistic and estrogen-antago- nistic properties when ingested orally in large quanti- ties [110, 111]. Two specific dietary isoflavones, genistein and daid- zein, are found in high concentrations in legumes such as soy, chickpeas, lentils, and red clover. Initial inter - est in these compounds for the management of VMS stemmed from the observation that Asian women, who traditionally consume large quantities of soy in their diet, appear to have lower rates of menopausal symp- toms [110, 112]. A 2013 Cochrane meta-analysis was performed on 43 randomized, controlled studies of 4,084 patients to assess the efficacy and safety of food products, extracts, and supplements containing high levels of phytoestro- gens in the amelioration of VMS in perimenopausal and postmenopausal women. The authors summarized that no conclusive evidence shows that phytoestrogen supplements effectively reduce the frequency or sever- ity of hot flushes and night sweats in perimenopausal or postmenopausal women, although benefits derived from concentrates of genistein should be further inves- tigated [110]. Various supplements that have been used in the management of VMS include  Dioscorea villosa or wild yams, evening primrose, dong quai, American ginseng, kava kava, and St. John’s wort. The evidence from clin- ical trials demonstrating benefit is conflicting and lim- ited [111, 113, 114]. Therefore, current guidelines do not support the use of such agents at this time [111]. There has been a lot of conflicting information with regards to black cohosh, scientific name  Actaea race- mosa L (previously  Cimicifugae racemosae),which has been used by Native Americans to treat malaria, im- paired kidney function, sore throat, rheumatism, mal- aise, and menstrual irregularities [115]. The rhizome of black cohosh contains a number of biologically active constituents (including the triterpene glycosides actein and cimicifugoside, as well as fatty acids, resins, caffe- ic acids, isoferulic acids and isoflavones) [116], but the mechanism of action is unclear [111]. A 2012 Cochrane review [117] analyzed 16 random- ized controlled trials of 2,027 perimenopausal or post- menopausal women treated with black cohosh using a median daily dose of 40 mg for a mean duration of 23 weeks. There was no significant difference between black cohosh and placebo in the frequency of hot flash- es. Data on safety were also inconclusive. The authors concluded that, at that time, there was insufficient ev- idence to support the use of black cohosh for meno- pausal symptoms. Black cohosh appears to have no effect on circulating luteinizing hormone, follicle-stim- ulating hormone, prolactin, or estradiol. A  52-week study reassuringly demonstrated that black cohosh does not increase endometrial thickness on ultrasound [118]. Reports of possible hepatotoxicity started to ap- pear after 2000; however, after examining all report- ed cases, the US Pharmacopeial Convention’s Dietary Supplements-Botanicals Expert Committee found only 30 reports possibly related to black cohosh. Eventual- ly, the committee issued a directive that black cohosh products carry a  warning statement: Discontinue use and consult a healthcare practitioner if you have a liver disorder or develop symptoms of liver trouble, such as abdominal pain, dark urine, or jaundice [111]. Additionally, the NAMS in the 2015 position state- ment on nonhormonal management of menopause stated that there are negative, insufficient, or inconclu- sive data suggesting that the following should not be recommended as proven therapies for managing VMS: cooling techniques, avoidance of triggers, exercise, yoga, paced respiration, relaxation, over-the-counter supple- ments and herbal therapies, acupuncture, calibration of neural oscillations, and chiropractic interventions [111]. Although there are many health benefits associated with the aforementioned therapies, attempts to use them are likely to delay receipt of more appropriate and effective Menopause Review/Przegląd Menopauzalny 20(2) 2021 96 therapies. In symptomatic women, such delays should be avoided given the association of VMS with other symptoms and overall quality of life [111]. Incorporating the available evidence into clini- cal practice will help ensure that women receive evi- dence-based recommendations along with appropriate cautions for appropriate and timely management of VMS [111].

Gynecologists can have a significant impact on the health of the elderly female patient as specialists and primary care physicians. Nowadays, most women spend more than one-third of their lives after menopause [92]. Therefore, there is plenty of opportunity for gynecolo- gists to cater to the needs of postmenopausal women. Disclosure The authors report no conflict of interest.

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