Initial evaluation in the climacteric

Key points

• Climacteric syndrome is a set of signs and symptoms resulting from the interaction between sociocultural, psychological and endocrine factors occurring in aging women. Its diagnosis is clinical in women with the expected age group for ovarian hypofunction. The term “menopause” refers to the date of the woman's last menstrual bleeding episode and is defined retrospectively.

• Women in menopausal transition have disease prevention and health promotion needs. Hypoestrogenism associated with aging and metabolic syndrome can lead to lower quality of life and increased occurrence of cardiovascular disease.

• The medical consultation of climacteric women is an excellent opportunity of screening for chronic diseases and neoplasms.

• Complementary evaluation for climacteric women must be carried out judiciously. The benefit and risk of each test must be considered. Complementary tests without a specific definition of a diagnostic and therapeutic plan should be avoided.

• Menopausal hormone therapy (HT) may be indicated to treat climacteric symptoms. Detailed clinical history and rational complementary exams are essential to define the therapeutic plan and follow-up of women undergoing HT.

The National Specialty Commission on Climateric of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO) endorses to this document. The content production is based on scientific studies on a thematic proposal and the findings presented contribute to clinical practice.

Publication History

Article published online:
13 June 2022

• References

• 1 Utian WH. Ovarian function, therapy-oriented definition of menopause and climacteric. Exp Gerontol 1994; 29 (3-4): 245-51 DOI: 10.1016/0531-5565(94)90003-5.
• 2 Ministério da Saúde. Instituto Sírio-Libanês de Ensino e Pesquisa. Protocolos da atenção básica: saúde das mulheres. Brasília (DF): Ministério da Saúde; 2016
• 3 Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW. et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. J Clin Endocrinol Metab 2012; 97 (04) 1159-68 DOI: 10.1210/jc.2011-3362.
• 4 Welt CK. Ovarian development and failure (menopause) in normal women [Internet]. 2020 [cited 2020 Jun 21]. Available from: https://www.uptodate.com/contents/ovarian-development-and-failure-menopause-in-normal-women
• 5 Federação Brasileira das Associações de Ginecologia e Obstetrícia. Insuficiência ovariana prematura. São Paulo: Febrasgo; 2021. . (Protocolo Febrasgo-Ginecologia, no. 26/Comissão Nacional Especializada em Ginecologia Endócrina)
• 6 Shifren JL, Gass ML. NAMS Recommendations for Clinical Care of Midlife Women Working Group. The North American Menopause Society recommendations for clinical care of midlife women. Menopause 2014; 21 (10) 1038-62 DOI: 10.1097/GME.0000000000000319.
• 7 Voda AM. Climacteric hot flash. Maturitas 1981; 3 (01) 73-90 DOI: 10.1016/0378-5122(81)90022-0.
• 8 Kaunitz AM, Manson JE. Management of menopausal symptoms. Obstet Gynecol 2015; 126 (04) 859-76 DOI: 10.1097/AOG.0000000000001058.
• 9 Casper RF. Clinical manifestations and diagnosis of menopause [Internet]. 2020 [cited 2020 Jun 21]. Available from: https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause
• 10 Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva. Estimativa 2020: incidência de câncer no Brasil [Internet]. Rio de Janeiro: INCA; 2019. [cited 2020 Jun 1]. Available from: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//estimativa-2020-incidencia-de-cancer-no-brasil.pdf
• 11 Pompei LM, Machado RB, Wender MC, Fernandes CE. Consenso Brasileiro de Terapêutica Hormonal da Menopausa – Associação Brasileira de Climatério (Sobrac). São Paulo: Leitura Médica; 2018
• 12 Siu AL. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2016; 164 (04) 279-96 DOI: 10.7326/M15-2886.
• 13 Urban LA, Chala LF, Bauab SP, Schaefer MB, Santos RP, Maranhão NM. et al. Breast cancer screening: updated recommendations of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Breast Disease Society, and Brazilian Federation of Gynecological and Obstetrical Associations. Radiol Bras 2017; 50 (04) 244-9 DOI: 10.1590/0100-3984.2017-0069.
• 14 Committee on Practice Bulletins - Gynecology. Practice Bulletin Number 179: breast cancer risk assessment and screening in average-risk women. Obstet Gynecol 2017; 130 (01) e1-e16 DOI: 10.1097/AOG.0000000000002158.
• 15 Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva. Diretrizes brasileiras para o rastreamento do câncer do colo do útero [Internet]. 2a ed.. Rio de Janeiro: INCA; 2016. [cited 2020 Jun 21]. Available from: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//diretrizesparaorastreamentodocancerdocolodoutero_2016_corrigido.pdf
• 16 Federação Brasileira das Associações de Ginecologia e Obstetrícia. Rastreio, diagnóstico e tratamento do câncer de colo de útero. São Paulo: Febrasgo; 2017
• 17 Menon U, Gentry-Maharaj A, Burnell M, Singh N, Ryan A, Karpinskyj C. et al. Ovarian cancer population screening and mortality after long-term follow-up in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. Lancet 2021; 397 (10290): 2182-93 DOI: 10.1016/S0140-6736(21)00731-5.
• 18 Pinsky PF, Yu K, Kramer BS, Black A, Buys SS, Partridge E. et al. Extended mortality results for ovarian cancer screening in the PLCO trial with median 15years follow-up. Gynecol Oncol 2016; 143 (02) 270-5 DOI: 10.1016/j.ygyno.2016.08.334.
• 19 Chen L, Berek JS. Endometrial carcinoma: clinical features, diagnosis, prognosis, and screening [Internet]. 2021 [cited 2021 Jul 12]. Available from: https://www.uptodate.com/contents/endometrial-carcinoma-clinical-features-diagnosis-prognosis-and-screening
• 20 Committee Opinion No. 716: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer in women at average risk. Obstet Gynecol 2017; 130 (03) e146-9 DOI: 10.1097/AOG.0000000000002299.
• 21 Wolf AM, Fontham ET, Church TR, Flowers CR, Guerra CE, LaMonte SJ. et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018; 68 (04) 250-81 DOI: 10.3322/caac.21457.
• 22 World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: WHO; 2013
• 23 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Rastreamento [Internet]. Brasília (DF): Ministério da Saúde; 2010. [cited 2020 Jun 23]. (Caderno de Atenção Básica; no. 29). Available from: http://189.28.128.100/dab/docs/publicacoes/cadernos_ab/abcad29.pdf
• 24 Lobo RA. Hormone-replacement therapy: current thinking. Nat Rev Endocrinol 2017; 13 (04) 220-31 DOI: 10.1038/nrendo.2016.164.
• 25 Précoma DB, Oliveira GM, Simão AF, Dutra OP, Coelho OR, Izar MC. et al. Updated Cardiovascular Prevention Guideline of the Brazilian Society of Cardiology – 2019. Arq Bras Cardiol 2019; 113 (04) 787-891 DOI: 10.5935/abc.20190204.
• 26 Rosen HN, Drezner MK. Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women [Internet]. 2020 [cited 2020 Jun 21]. Available from: https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-evaluation-of-osteoporosis-in-postmenopausal-women
• 27 Albergaria BH, Paula FJ. The Algorhytm: FRAX Brazil. Rev Bras Ginecol Obstet 2019; 41 (08) 467-8 DOI: 10.1055/s-0039-1695027.
• 28 Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S. et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int 2014; 25 (10) 2359-81 DOI: 10.1007/s00198-014-2794-2.
• 29 Maki PM, Kornstein SG, Joffe H, Bromberger JT, Freeman EW, Athappilly G. et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause 2018; 25 (10) 1069-85 DOI: 10.1097/GME.0000000000001174.
• 30 Santos IS, Tavares BF, Munhoz TN, Almeida LS, Silva NT, Tams BD. et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saúde Pública 2013; 29 (08) 1533-43 DOI: 10.1590/0102-311X0014461.
• 31 Heinemann LA, Potthoff P, Schneider HP. International versions of the Menopause Rating Scale (MRS). Health Qual Life Outcomes 2003; 1: 28 DOI: 10.1186/1477-7525-1-28.
• 32 Baill IC, Castiglioni A. Health maintenance in postmenopausal women. Am Fam Physician 2017; 95 (09) 561-70
• 33 Brenta G, Vaisman M, Sgarbi JA, Bergoglio LM, Andrada NC, Bravo PP. et al. Clinical practice guidelines for the management of hypothyroidism. Arq Bras Endocrinol Metabol 2013; 57 (04) 265-91 DOI: 10.1590/s0004-27302013000400003.
• 34 Mohammed K, Abu Dabrh AM, Benkhadra K, Al Nofal A, Carranza Leon BG, Prokop LJ. et al. Oral vs transdermal estrogen therapy and vascular events: a systematic review and meta-analysis. J Clin Endocrinol Metab 2015; 100 (11) 4012-20 DOI: 10.1210/jc.2015-2237.
• 35 Goff Jr DC, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB, Gibbons R. et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129 (25 Suppl 2): S49-73 DOI: 10.1161/01.cir.0000437741.48606.98.
• 36 Archer DF, Pickar JH, Bottiglioni F. Bleeding patterns in postmenopausal women taking continuous combined or sequential regimens of conjugated estrogens with medroxyprogesterone acetate. Menopause Study Group. Obstet Gynecol 1994; 83 (5 Pt 1): 686-92
• 37 Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause 2013; 20 (09) 888-902 DOI: 10.1097/GME.0b013e3182a122c2.