New Clinical Guideline Helps Keep Women 'Optimized for the Fight'

The Department of Veterans Affairs and War Department have jointly released a clinical practice guideline to help clinicians provide improved care for women experiencing perimenopause and menopause.

"We want both patients and clinicians to know there are safe and effective treatments for women who are experiencing bothersome symptoms of perimenopause and menopause," said Air Force Maj. Kathleen Pombier, chief of the Defense Health Agency's women's health clinical management team. "Individualized treatment is key. The focus needs to be on whole-person care."

The guideline's recommendations cover diagnosis, menopausal symptom management and treatment safety. Topics include hot flashes, sleep problems, mood and cognitive changes, genitourinary symptoms, sexual dysfunction, bone health, weight management, cardiovascular disease and breast cancer risk.

Supporting Military Readiness

Women are an essential and growing part of the military force as well as the fastest-growing group among veterans and VA healthcare beneficiaries, Pombier said. The guideline provides a common framework for a continuity of care across both healthcare systems.

"When we look at the VA, the average age of those patients is within the perimenopausal and menopausal range," said Army Col. Erin Keyser, director of medical education at Brooke Army Medical Center, San Antonio. "This is a very important issue for these patients."

Perimenopause and menopause are natural life transitions during which a woman's menstrual periods stop permanently, and she is no longer able to become pregnant - with perimenopause referring to the time leading up to menopause, according to the National Institutes of Health.

Hormonal changes can disrupt sleep, mood, cognition and daily functioning for some patients, ultimately impacting readiness, Pombier said.

"When your sleep's affected, you're not going to do your job as well," she emphasized, adding that identifying and treating symptoms early helps women remain ready to serve.

"By having clinicians identify symptoms earlier and recognize that it's not something women just have to deal with - it's actually something we can treat - it ensures we have every woman optimized for the fight," she said.

Effective care can also reduce stigma and help women stay in the military and pursue leadership opportunities, Keyser said.

Tailoring Treatment to Each Patient

Treatment decisions should reflect each patient's symptoms, health history, preferences and risks, Pombier said.

Diagnosis generally relies on symptoms and a discussion with the patient.

For vasomotor symptoms, like hot flashes and night sweats, the guideline addresses hormonal treatments including estrogen, progesterone and nonhormonal options, including certain antidepressants and gabapentin. Nonhormonal treatments may help women who cannot use systemic hormones or prefer other options.

The guideline also addresses treatment for breast cancer survivors.

"Many breast cancer survivors don't know local estrogen is still an option, even with a history of breast cancer," she said. "We also have multiple other nonhormonal options for this specific patient population which are covered in the [guideline]."

Other recommendations address sleep, mood, genitourinary and sexual-health concerns, which may arise during menopause.

"For sleep symptoms, we talk a lot about cognitive behavioral therapy for insomnia, which is one of the strong evidence-based methods we can use to help women when they're struggling," Pombier said.

She stressed that care must be individualized.

"We need to recognize the midlife transition, talk to our patient, assess their symptoms, understand their priorities, review with them the risks and the benefits and ultimately use shared decision-making to figure out how we should best treat them," she said.

Practical Tools for Clinicians

The guideline includes four diagnostic and treatment flowcharts for diagnosis and a pocket card that matches symptoms with recommended treatments.

Providers can use these tools during appointments to determine whether one treatment could address several concerns.

The tools also help clinicians at remote military hospitals and clinics without an obstetrician or gynecologist on staff, Keyser said. The guideline directs providers to related clinical guidance when patients need further evaluation or treatment.

"Everyone deserves to have high-quality care regardless of where they're stationed," she added.

For Pombier, the shared standards support consistent care across specialties and help service members transition to VA care.

The working group developed the recommendations using patient focus groups and systematic evidence reviews. It weighed evidence quality, benefits and harms, patient preferences and access to care.

"We wanted to be transparent on the basis for care," Pombier said. "Here is the evidence that we have, here is how strong or weak it is, but also here are the areas where we think we need more evidence before we can make firm recommendations."

Keyser said the guideline demonstrates a commitment to addressing menopause-related concerns.

"We are taking this subject seriously, and we care about the women in our healthcare system," she said. "We want to provide them high-quality care."