EMAS Position Statements and Clincial Guides
Menopause, wellbeing and health: A care pathway from the European Menopause and Andropause SocietyLife expectancy has considerably increased since 1970 , and now >50% of women are expected to break the 90-year barrier by 2030 . Growing older rather than old means spending almost half of life after the menopause, challenging the concept of healthy ageing . Iatrogenic menopause may be induced by cancer treatment or bilateral salpingo-oophorectomy for benign disease and may occur before the average age of natural menopause, which is around the age of 50 [4,5]. The sudden fall in estrogen levels with iatrogenic menopause may lead to rapid onset of vasomotor symptoms .
The essential menopause curriculum for healthcare professionals: A European Menopause and Andropause Society (EMAS) position statementWomen's health is increasingly recognized as a global health priority . The menopause, or the cessation of menstruation, is a stage of the life cycle which will occur in all women. The average age at menopause is 51 years. With increasing life expectancy many women will live for several decades after the menopause. However, the menopause can occur much earlier, either naturally, with no identifiable underlying cause , or as a consequence of disease, surgery, radiotherapy or chemotherapy. The resulting estrogen deficiency may lead to menopausal symptoms which, for some, can present considerable difficulties in their working lives, discrimination in the workplace and even unemployment .
Global consensus recommendations on menopause in the workplace: A European Menopause and Andropause Society (EMAS) position statementThe menopause, or the cessation of menstruation, is a normal stage of life. The average age of the menopause is 51 years. However, it can occur much earlier, either naturally, with no identifiable underlying cause , or as a consequence of disease, surgery, radiotherapy or chemotherapy. In 2020, globally 657 million women were aged 45–59  (Fig. 1). Overall, 47% of these women worldwide contributed to the labor force, but the figures varied both regionally, ranging from 22% to 63%, as well as by age: 64%, 59%, 51%, at age 45–49, 50–54, and 55–59 respectively .
Topical estrogens and non-hormonal preparations for postmenopausal vulvovaginal atrophy: An EMAS clinical guideVulvovaginal atrophy (VVA), a component of genitourinary syndrome of menopause (GSM), is caused by estrogen deficiency. It is characterized by symptoms of dryness, burning, itching and dyspareunia . It is well established that it has a negative impact on a woman's general and sexual quality of life as well as the quality of her personal relationships . VVA is also associated with urinary tract problems, such as frequent urination, urge incontinence and recurrent urinary tract infections. GSM includes both genital and urinary symptoms .
Management of urinary incontinence in postmenopausal women: An EMAS clinical guideUrinary incontinence (UI) is defined as a “complaint of involuntary loss of urine” . The prevalence of the condition increases with age, and it is reported to affect 58%–84% of elderly women . The reported prevalence of UI varies widely because of the different definitions and assessment tools for diagnosis employed . The general prevalence is reported to be between 38 % and 55 % in women over 60 years . Despite this high prevalence, UI remains underdiagnosed and undertreated. Up to half of women may not report incontinence to their healthcare provider and this may be due to embarrassment or to the belief that UI is a normal part of aging.
The Mediterranean diet and menopausal health: An EMAS position statementWomen are living longer. The United Nations has estimated that, worldwide, 985 million women in 2020 are aged 50 and over. The figure is expected to rise to 1.65 billion by 2050 . Not surprisingly, the immediate and long-term sequelae of postmenopausal estrogen deficiency and aging present an enormous problem to healthcare systems. There are increasing concerns about non-communicable diseases (NCDs) such as cardiovascular disease (CVD), osteoporosis, dementia, and cognitive decline, which can adversely affect quality of life and independent living.
Menopause symptom management in women with dyslipidemias: An EMAS clinical guideWorldwide, dyslipidemias are one of the leading causes of cardiovascular disease, mainly coronary heart disease . Dyslipidemias are also associated with an increased risk of ischemic stroke . Dyslipidemias embrace a wide constellation of lipid and lipoprotein abnormalities. Lipoproteins bind lipids and are involved in their transport. Lipid abnormalities include high serum concentrations of low-density lipoprotein (LDL) cholesterol (LDL-C) and/or triglycerides and/or low concentrations of high-density lipoprotein (HDL) cholesterol (HDL-C).
Management of depressive symptoms in peri- and postmenopausal women: EMAS position statementThe European Menopause and Andropause Society (EMAS) aims to provide holistic consensus advice on the clinical management of menopausal women through its position statements and clinical guides . EMAS’s healthcare model for healthy menopause covers physical, psychological and social functioning, and incorporates disability and disease . This position statement sets out a model of care for the management of depressive symptoms and depressive episodes in peri- and postmenopausal women, integrating services provided by healthcare and allied professionals.
Drug holidays from bisphosphonates and denosumab in postmenopausal osteoporosis: EMAS position statementBisphosphonates are structural analogues of inorganic pyrophosphate, where the oxygen atom has been substituted by a carbon atom. Differences in the R2 side-chain bound to the carbon atom and the nitrogen group determine their variations in duration of action, bone affinity and anti-fracture efficacy [1,2]. Bisphosphonates inhibit enzymes involved in osteoclastic activity, and thus suppress bone resorption [1,2]. The main bisphosphonates are alendronate, risedronate, ibandronate and zoledronic acid, which constitute the first-line therapeutic agents in both postmenopausal and male osteoporosis, as they have well-documented anti-fracture efficacy [1,2].
Interventions to reduce the risk of ovarian and fallopian tube cancer: A European Menopause and Andropause Society Position StatementApproximately 1.3% of women will be diagnosed with ovarian cancer at some point during their life. Mortality is high, with a 5-year survival rate ranging from 36% to 46%, although there has been a net survival improvement during the last decades, especially among young and mid-aged women [1,2].
Osteoporosis management in patients with breast cancer: EMAS position statementBreast cancer remains the most frequent cancer in women and its incidence is increasing. However, the mortality rate has stabilized due to the progress made in the treatment of breast cancer over the last decade. In premenopausal women with hormone receptor-positive breast cancer, the goal of adjuvant treatment is to inhibit the impact of estrogen on the breast, either by blocking the estrogen receptors (with the use of tamoxifen) or by suppressing ovarian function (through surgical oophorectomy or treatment with luteinizing hormone-releasing hormone (LHRH) agonist).
A model of care for healthy menopause and ageing: EMAS position statementThe menopause can now be considered to be a mid-life event as the lifespan of women continues to increase in developed countries . By the year 2025, the number of postmenopausal women is expected to rise to 1.1 billion worldwide. Although not all women will experience short- or long-term problems of menopause, the high prevalence of hot flushes [2,3] and vaginal atrophy [2,4], which can last for many years, as well as osteoporosis (1 in 3 women are at risk of an osteoporotic fracture) , makes caring for ageing women a key issue for health professionals.
Maintaining postreproductive health: A care pathway from the European Menopause and Andropause Society (EMAS)This position statement from the European Menopause and Andropause Society (EMAS) provides a care pathway for the maintenance of women’s health during and after the menopause. It is designed for use by all those involved in women’s health. It covers assessment, screening for diseases in later life, treatment and follow-up. Strategies need to be optimised to maintain postreproductive health, in part because of increased longevity. They encompass optimising diet and lifestyle, menopausal hormone therapy and non-estrogen-based treatment options for climacteric symptoms and skeletal conservation, personalised to individual needs.
EMAS recommendations for conditions in the workplace for menopausal womenOccupational health issues for older workers in general, and older women workers in particular, have often been ignored. Women form a large part of many workforces throughout Europe. The number of persons in employment in EU Member States rose between 2013 and 2014 by around 2.3 million, to 217.8 million in 2014 . The employment rate for men was just over 70%, and for women, nearly 60%. A longer-term comparison shows that while the employment rate for men in 2014 was below its corresponding level ten years earlier, there was a marked increase in the proportion of women in employment.
EMAS position statement: Testosterone replacement therapy in the aging maleAging or the process of becoming older represents the accumulation of physical, psychological, and social changes in a human being over time, ultimately resulting in death. Late-onset hypogonadism (LOH) is characterized by decreasing circulating testosterone concentrations, in combination with a spectrum of clinical symptoms and signs, during normal aging .
EMAS position statement: Non-hormonal management of menopausal vasomotor symptomsTo review non-hormonal therapy options for menopausal vasomotor symptoms. The current EMAS position paper aims to provide to provide guidance for managing peri- and postmenopausal women who cannot or do not wish to take menopausal hormone therapy (MHT).
EMAS position statement: The ten point guide to the integral management of menopausal healthWith increased longevity and more women becoming centenarians, management of the menopause and postreproductive health is of growing importance as it has the potential to help promote health over several decades. Women have individual needs and the approach needs to be personalised. The position statement provides a short integral guide for all those involved in menopausal health. It covers diagnosis, screening for diseases in later life, treatment and follow-up.
EMAS position statement: Individualized breast cancer screening versus population-based mammography screening programmesBreast cancer originates from the malignant transformation of epithelial cells within the ducts and lobules of the breast. A malignant cell is the result of the accumulation of consecutive mutations. Up or down regulation of different mutated genes will ultimately result in the heterogeneity of breast cancers . Some tumors will remain in situ and will never threaten the health of women. Other tumors will become invasive and ultimately metastasize and hence be fatal when not treated. The doubling time of tumor cells is estimated between 150 and 200 days .
EMAS position statement: Management of uterine fibroidsUterine fibroids (also termed leiomyomas or myomas) are the most common tumors of the female reproductive tract.
EMAS position statement: The management of postmenopausal women with vertebral osteoporotic fractureOsteoporotic vertebral fractures are associated with significant morbidity, excess mortality as well as health and social service expenditure. Additionally, women with a prevalent osteoporotic vertebral fracture have a high risk of experiencing a further one within one year. It is therefore important for the physician to use a diagnostic and therapeutic algorithm for early detection and effective treatment of vertebral fractures.
EMAS position statement: Menopause for medical studentsDiscussions with patients about the menopause are becoming more complex because of women's increasing longevity, the wide range of therapeutic options, the controversies regarding menopausal hormone therapy (MHT) and the increasing use of alternative and complementary therapies. The aim of this document is to provide guidance in bullet-point style on the essential issues that medical students need to know about the stages of reproductive aging, menopause terminology, menopause and postmenopausal health .
EMAS position statement: Fertility preservationThe increasing incidence of malignant diseases that often require gonadotoxic treatment and the tendency to become a parent later in life result in an increased need for fertility preservation.
EMAS position statement: Late parenthoodDuring the last decades, couples in Europe have been delaying parenthood, mainly due to socio-demographic factors that include increased rates of university education and employment in women and poorer financial status.
EMAS clinical guide: Assessment of the endometrium in peri and postmenopausal womenInvasive as well as non-invasive methods are available for assessment of the endometrium.
EMAS clinical guide: Vulvar lichen sclerosus in peri and postmenopausal womenVulvar lichen sclerosus (LS) is a chronic inflammatory disease which affects genital labial, perineal and perianal areas, producing significant discomfort and psychological distress. However there may be diagnostic delay because of late presentation and lack of recognition of symptoms.