Commentary on Indian Menopause Society Guidelines.

The process of menopause is a significant occurrence in the life of a woman as she transits from the reproductive to the nonreproductive phase.[1] Although cessation of ovarian function primarily characterizes it, this has far-reaching implications that could alter her health-related quality of life.[2] Clinical manifestations in menopause range from vasomotor symptoms to various noncommunicable diseases such as hypertension, diabetes mellitus, cardiovascular disease, and osteoporosis.[3] Over the years, there have been guidelines put forth by various prestigious bodies to address different issues pertaining to menopause.[4] These guidelines have stood the test of time more often than not; however, in a nation as diverse as ours, these may not be applicable in its entirety.

As far as the menopausal transition is concerned, Indian women differ from their western counterparts in that menopause occurs earlier at a mean age of 46 years,[5] noncommunicable diseases set in almost a decade sooner and the peak bone mineral density is about two standard deviations lower. These attributes need to be taken into account while formulating guidelines for menopause.[6]

In this issue, the Indian Menopause Society has proposed a comprehensive set of guidelines that adopts a holistic approach to the care of women before and following menopause.[7] Numerous issues, including aspects pertaining to fertility, oral contraceptive use, hormone replacement therapy, and postmenopausal bleeding, have been extensively covered. Vasomotor symptoms though seemingly innocuous, maybe potentially disturbing though treatable.

Osteoporosis constitutes a significant public health problem that often goes unrecognized among postmenopausal women.[89] Untreated osteoporosis could potentially lead to fragility fractures, which are associated with increased mortality, morbidity, and a poor health-related quality of life in affected individuals.[10] They also prove to be economically costly, both for the individual and the community at large. Early screening and detection of osteoporosis and timely initiation of therapeutic measures will likely help in reducing these adverse consequences and the costs incurred thereof. Although Dual Energy X-ray Absorptiometry is the gold standard in diagnosing osteoporosis, there are constraints with respect to its widespread availability and high costs. In such instances, a risk factor assessment based on clinical cues (e.g., dentition) or use of easily available screening tools such as FRAX®(Fracture risk assessment tool) Osteoporosis Screening Tool for Asians and Simple Calculated Osteoporosis Risk Evaluation may be utilized to refer those women at high risk for the same.[111213] Osteoarthritis is addressed by lifestyle modification, physical therapy, and pharmacotherapy, with knee replacement surgery recommended for very severe cases.

In addition, adequate control of comorbidities such as diabetes and hypertension, avoidance of excessive alcohol consumption, maintaining an active mind, and practising good sleep hygiene helps in promoting good health. Screening for breast cancer and other gynecological malignancies may be carried out as deemed relevant.

Specific guidelines addressing women's health issues seem to be the need of the hour. Recommendations pertaining to menopausal symptoms, bone health, use of hormone replacement therapy, control of comorbidities, and screening for cancer encompass the wide clinical spectrum of postmenopausal women. Notwithstanding, clinical decisions in the milieu of these guidelines need to be individualized with careful attention to the patient's presentation and symptomatology.