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## Complete Summary

#### GUIDELINE TITLE

Management of osteoporosis in postmenopausal women: 2006 position
statement of The North American Menopause Society.

#### BIBLIOGRAPHIC SOURCE(S)

North American Menopause Society (NAMS). Management of osteoporosis in
postmenopausal women: 2006 position statement of The North American
Menopause Society. Menopause 2006 May-Jun;13(3):340-67. \[234
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16735931)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Management of postmenopausal
osteoporosis: position statement of the North American Menopause
Society. Menopause 2002 Mar-Apr;9(2):84-101.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Postmenopausal osteoporosis

-   Postmenopausal osteoporotic fracture

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Diagnosis\
Evaluation\
Management\
Prevention\
Risk Assessment\
Screening

#### CLINICAL SPECIALTY

Endocrinology\
Family Practice\
Geriatrics\
Internal Medicine\
Nutrition\
Obstetrics and Gynecology\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Health Plans\
Managed Care Organizations\
Nurses\
Pharmacists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To update the evidence-based position statement published by The
    North American Menopause Society (NAMS) in 2002 regarding the
    management of postmenopausal osteoporosis

-   To provide guidance on the diagnosis, prevention, and treatment of
    osteoporosis in postmenopausal women to physicians, physician
    assistants, nurse practitioners, nurses, and other healthcare
    professionals caring for postmenopausal women, especially those in
    the clinical practice fields of obstetrics and gynecology, internal
    medicine, family medicine, and geriatrics

#### TARGET POPULATION

Postmenopausal women in North America

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Risk Factor Assessment**

1.  Assessment for risk factors associated with osteoporosis and
    fracture including a history, physical examination, and any
    necessary diagnostic tests

2.  Bone mineral density measurement (dual-energy x-ray absorptiometry
    (DXA) is the technical standard)

3.  Interpretation and clinical application of T-scores

4.  Evaluation for secondary causes of osteoporosis

    -   Routine tests, including complete blood cell count plus serum
        levels of calcium, 25-hydroxyvitamin D, alkaline phosphatase and
        albumin, and urinary calcium excretion

    -   Special tests, as indicated, including measurement of
        thyroid-stimulating hormone, urinary cortisol, serum protein
        electrophoresis, and parathyroid hormone

**Prevention/Management/Treatment**

1.  Lifestyle approaches to prevent bone loss and fractures

    -   Nutrition, including adequate intakes of calcium, vitamin D,
        vitamin K, magnesium

    -   Isoflavones (considered but not recommended)

    -   Exercise

    -   Fall prevention

    -   Smoking cessation

    -   Alcohol avoidance

2.  Pharmacologic approaches for the prevention and/or treatment of
    osteoporosis

    -   Estrogen or estrogen plus progestin therapy (ET/EPT)

    -   Bisphosphonates (alendronate, risedronate, ibandronate,
        etidronate)

    -   Selective estrogen-receptor modulators (SERMs), such as
        raloxifene

    -   Parathyroid hormone (teriparatide, PTH 1-34)

    -   Calcitonin

    -   Combination therapies

    -   New/experimental therapies: zoledronic acid, additional SERMs
        (lasofoxifene, arzoxifene, and basodoxifene), PTH 1-84,
        tibolone, denosumab, and strontium ranelate (considered but no
        specific recommendations made)

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of postmenopausal osteoporosis and osteoporotic fracture

-   Changes in bone mineral density

-   Risk of postmenopausal osteoporosis and osteoporotic fracture

-   Morbidity and mortality associated with osteoporotic fracture

-   Effect of osteoporosis therapy on bone loss and risk for fracture

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The North American Menopause Society conducted a search of the medical
literature published since the previous position statement was submitted
for publication in November 2001. A search was made for clinical trials,
meta-analyses, and clinical practice guidelines published in English and
related to osteoporosis in postmenopausal women using the database
MEDLINE. The Medical Subject Headings (MeSH) used for the search were
postmenopausal osteoporosis and bone loss with subheadings for
epidemiology, etiology, diagnosis, prevention and control, and therapy.
The National Guideline Clearinghouse was searched for relevant clinical
practice guidelines and the Cochrane Library was searched for relevant
systematic reviews. Priority was given to evidence from randomized
controlled clinical trials and meta-analyses of such trials, followed by
evidence from controlled observational studies, using criteria described
elsewhere. Conclusions from other evidence-based guidelines also were
reviewed.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The North American Menopause Society (NAMS) enlisted a five-person
Editorial Board composed of endocrinologists and gynecologists from both
clinical practice and research, with expertise in metabolic bone
diseases and/or women\'s health. The Editorial Board reviewed the
previous position statement and incorporated data published since that
statement, compiled supporting statements, and made recommendations.
Where the evidence was contradictory or inadequate to form a conclusion,
a consensus-based opinion was established.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The North American Menopause Society Board of Trustees was responsible
for the final review and approval of this document. It was edited,
modified, and subsequently approved by The North American Menopause
Society on February 24, 2006.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Management strategies for osteoporosis in postmenopausal women require
assessment of risk factors for bone mineral density (BMD)-defined
osteoporosis and osteoporotic fracture, followed by institution of
measures that focus on reducing risk factors through lifestyle changes
and, if indicated, pharmacologic therapy.

-   All postmenopausal women should be encouraged to employ lifestyle
    practices that reduce the risk of bone loss and osteoporotic
    fractures: maintaining a healthy weight, eating a balanced diet,
    obtaining adequate calcium and vitamin D, participating in
    appropriate exercise, avoiding excessive alcohol consumption, not
    smoking, and using measures to prevent falls. Periodic reviews of
    calcium and vitamin D intake and lifestyle behaviors are useful.
    After menopause, a woman\'s risk of falls should be assessed at
    least annually.

-   The physical examination should include an annual measurement of
    height and weight, along with an assessment for kyphosis and back
    pain.

-   BMD testing is indicated for:

    -   All postmenopausal women with medical causes of bone loss

    -   All postmenopausal women aged 65 and older

> BMD testing should be considered for healthy postmenopausal women
> younger than age 65 who have one or more of the following risk
> factors:

-   Previous fracture (other than skull, facial bone, ankle, finger, and
    toe) after menopause

-   Thinness (body weight \<127 lb \[57.7 kg\] or BMI \<21 kg/m^2^)

-   History of hip fracture in a parent

-   Current smoking

> When BMD testing is indicated, dual energy x-ray absorptiometry (DXA)
> is the preferred technique. The total hip, femoral neck, and
> posterior-anterior lumbar spine should be measured, using the lowest
> of the three BMD scores.

-   The routine use of biochemical markers of bone turnover in clinical
    practice is not generally recommended.

-   If osteoporosis is diagnosed, either clinically or by BMD, any
    secondary causes should be identified, although the data defining
    the most thorough or cost-effective workup are limited.

-   Vertebral fracture must be confirmed, through either a vertebral
    fracture assessment with DXA measurement of the spine or height loss
    of more than 20% (or 4 mm) of a vertebra on spinal radiograph.

-   In postmenopausal women, the need for prescription osteoporosis
    therapy is based on a combination of BMD and risk factors.
    Osteoporosis drug therapy is recommended in the following
    populations:

    -   All postmenopausal women who have had an osteoporotic vertebral
        fracture

    -   All postmenopausal women who have BMD values consistent with
        osteoporosis (i.e., T-score worse than or equal to −2.5)

    -   All postmenopausal women who have a T-score from −2.0 to −2.5
        plus at least one of the following risk factors for fracture:
        thinness, history of fragility fracture (other than skull,
        facial bone, ankle, finger, and toe) since menopause, and
        history of hip fracture in a parent

-   Treatment recommendations are based on both efficacy data and
    clinical parameters, which include magnitude of fracture risk, side
    effect profile, tolerability of specific drugs, extraskeletal risks
    and potential benefits, confounding diseases, cost, and patient
    preference, including choice of dosing. Selection of one therapy
    over another cannot be made on the basis of clinical evidence
    because head-to-head trials comparing the effectiveness of
    pharmacologic therapies to reduce fracture risk have not been
    conducted.

-   Bisphosphonates are the first-line drugs for treating postmenopausal
    women with osteoporosis. Alendronate and risedronate reduce the risk
    of both vertebral and nonvertebral fractures. Whether there are
    differences in fracture protection among the bisphosphonates is
    uncertain. It is likely that all produce greater relative and
    absolute fracture risk reductions in women with more severe
    osteoporosis.

-   The selective estrogen-receptor modulator (SERM) raloxifene is most
    often considered in postmenopausal women with low bone mass or
    younger postmenopausal women with osteoporosis who are at greater
    risk of spine fracture than hip fracture. It prevents bone loss and
    reduces the risk of vertebral fractures, but its effectiveness in
    reducing other fractures is uncertain. Extraskeletal risks and
    benefits are important when considering raloxifene therapy.

-   Teriparatide (PTH 1-34) is reserved for treating women at high risk
    of fracture, including those with very low BMD (T-score worse than
    −3.0) with a previous vertebral fracture. PTH improves BMD and
    reduces the risk of new vertebral and nonvertebral fractures. Dosage
    requirements (i.e., daily subcutaneous injections) may limit use.

-   The primary indication for systemic estrogen or estrogen-progestin
    therapy (ET/EPT) is to treat moderate to severe menopause symptoms
    (e.g., vasomotor symptoms). When symptoms are controlled or cease,
    continued hormone therapy can still be considered for bone effects,
    weighing its benefits and risks against those of alternate
    therapies.

-   Calcitonin is not a first-line drug for postmenopausal osteoporosis
    treatment, as its fracture efficacy is not strong and its BMD
    effects are less than those of other agents. However, it is an
    option for women with osteoporosis who are more than 5 years beyond
    menopause. Calcitonin therapy may reduce vertebral fracture risk in
    women with osteoporosis, although the evidence documenting fracture
    protection is not strong. It is not recommended for treating bone
    pain, except bone pain from acute vertebral compression fractures.

-   Data are inadequate to make definitive recommendations regarding
    combination or serial antiresorptive and anabolic drug therapy.

-   During therapy, it is appropriate to reevaluate the treatment goals
    and the choice of medication on an ongoing basis through periodic
    medical examination and follow-up BMD testing. Measurement of BMD
    has limited use in predicting the effectiveness of antiresorptive
    therapies for reducing fracture risk. Also, fracture risk reductions
    from therapy occur much more rapidly than bone density changes. An
    appropriate interval for repeat BMD testing is 2 years.

-   It is important to encourage adherence to the treatment plan and to
    identify barriers to nonadherence. Providing clear information to
    women regarding their risk of fracture and the purpose of
    osteoporosis therapy may be the optimal way to improve adherence.

-   If drug-related adverse effects occur, appropriate management
    strategies should be instituted. If adverse effects persist,
    switching to another agent may be required.

-   The treatment of osteoporosis needs to be long term in most women.

-   Decisions to discontinue or suspend therapy are based on the
    woman\'s risk of fracture and her response to treatment, as well as
    the likelihood of diminishing beneficial effects from the agent
    used. Given the uncertainties of long-term safety, careful
    monitoring is required. Fracture risk after discontinuing therapy
    has not been adequately evaluated.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The position statement was supported by evidence from randomized,
controlled clinical trials and meta-analyses of such trials, followed by
evidence from controlled observational studies and conclusions from
other evidence-based guidelines. If the evidence was contradictory or
inadequate to form a conclusion, a consensus-based opinion was
established.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management of postmenopausal osteoporosis may help prevent
fractures by slowing or preventing bone loss, maintaining bone strength,
and minimizing or eliminating factors that may contribute to falls.

#### POTENTIAL HARMS

Side effects and adverse reactions of therapy:

-   ***Bisphosphonates***. Esophageal and gastric irritation,
    particularly affecting individuals who dose inappropriately. A
    theoretical concern exists regarding possible oversuppression of
    bone turnover with long-term bisphosphonate therapy, resulting in a
    more brittle skeleton.

-   ***Raloxifene (a SERM)***. Raloxifene therapy may be associated with
    an increase in vasomotor symptoms.

-   ***Parathyroid hormone (PTH)***. Drug-related adverse effects
    include muscle cramps and infrequent hypercalcemia, nausea, and
    dizziness.

-   ***Estrogen plus progestin therapy (EPT)***. A significantly
    increased risk of breast cancer, stroke, coronary heart disease,
    thromboembolic events, and dementia.

-   ***Calcitonin***. Nausea, local inflammation, and flushing of the
    face or hands when given as an injection and local nasal irritation
    with the nasal spray formulation.

-   ***Calcium***. Calcium intervention trials have not reported any
    serious adverse events. Nevertheless, some women have difficulty
    swallowing the large tablet or have gastrointestinal (GI) adverse
    effects (i.e., gaseousness, constipation). Tolerability can be
    addressed by switching the type of calcium or reducing the dose. GI
    adverse effects are often related to taking more calcium than
    required, not dividing doses, or perhaps confusing supplemental
    intake with recommended total daily intake.

-   ***Vitamin D***. Doses higher than 2,000 IU/day may introduce risks
    such as hyper-calciuria and hypercalcemia.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Calcium supplements are contraindicated in a woman with a
    calcium-containing renal calculus until her urinary biochemical
    profile has been assessed. Larger amounts of calcium (\>2,500
    mg/day) should be avoided.

-   Vitamin K supplements are contraindicated in women taking warfarin.

-   Bisphosphonates may cause upper GI disorders such as dysphagia,
    esophagitis, and esophageal and gastric ulcer, a contraindication in
    those with esophageal abnormalities that delay esophageal emptying,
    or in those who are unable to stand or sit upright for at least 30
    to 60 minutes after ingestion.

-   Teriparatide should not be administered to postmenopausal women with
    hypercalcemia, bone metastases, or disorders that predispose them to
    bone tumors such as Paget\'s disease or those who received prior
    skeletal irradiation.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Because standards of care and available treatment options differ
throughout the world, the focus of this guideline is limited to
therapies available in North America.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Slide Presentation\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

North American Menopause Society (NAMS). Management of osteoporosis in
postmenopausal women: 2006 position statement of The North American
Menopause Society. Menopause 2006 May-Jun;13(3):340-67. \[234
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16735931)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Feb

#### GUIDELINE DEVELOPER(S)

The North American Menopause Society - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

The development of this position statement was supported by unrestricted
educational grants from the Novartis Pharmaceuticals Corporation.

#### GUIDELINE COMMITTEE

Editorial Board

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Board Members*: Bruce Ettinger, MD, Clinical Professor of Medicine,
University of California, San Francisco, CA; Steven T. Harris, MD, FACP,
Clinical Professor of Medicine, University of California, San Francisco,
CA; David Kendler, MD, Assistant Professor, University of British
Columbia, Vancouver, BC, Canada; Bruce Kessel, MD, Associate Professor,
Department of Obstetrics and Gynecology, and Women\'s Health, John A.
Burns School of Medicine, University of Hawaii, Honolulu, HI; and
Michael R. McClung, MD, Director, Oregon Osteoporosis Center, Portland,
OR

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The North American Menopause Society (NAMS) is committed to ensuring
balance, independence, and objectivity in all its educational
activities. All those involved in the development of a continuing
medical education (CME) activity are required to disclose financial
relationships they or their spouse/partner have had during the past 12
months with a commercial interest whose products or services are
discussed in the CME activity content, or with any commercial supporters
of the activity over which they have control.

For the Editorial Board, Dr. Ettinger reports Berlex, GlaxoSmithKline,
Novartis, Merck, Procter & Gamble, Roche (consultant); Dr. Harris
reports Amgen, Eli Lilly, GlaxoSmith-Kline, Merck, Novartis, Procter &
Gamble, Roche, Sanofi-Aventis, Wyeth (consultant), Eli Lilly,
GlaxoSmithKline, Merck, Procter & Gamble, Roche, Sanofi-Aventis, Wyeth
(sponsored lectures); Dr. Kendler reports Amgen, Eli Lilly, Merck,
Novartis, Pfizer, Servier, Wyeth (consultant, research support,
speakers\' bureau); Dr. Kessel reports Procter & Gamble, Wyeth (research
support), Berlex, Procter & Gamble, Merck, Wyeth (speakers\' bureau);
Dr. McClung reports Wyeth (consultant), Amgen, Eli Lilly, Merck,
Novartis, Pfizer, Sanofi-Aventis (consultant, research support).

For the NAMS Board of Trustees who are not serving on the Editorial
Board, Dr. Freedman reports Alexza, Duramed, GlaxoSmithKline, Novartis,
Organon, Pfizer, Vela, Wyeth (consultant), GlaxoSmithKline, National
Institutes of Health, Organon (research support); Dr. Gallagher reports
GlaxoSmithKline, Organon, Pfizer, Wyeth (consultant), Organon, Pfizer,
Wyeth (research support): Dr. Goldstein reports Eli Lilly, Merck,
Pfizer, Procter & Gamble, TAP (advisory boards); Dr. Gorodeski reports
Molecular Diagnostics (advisory board); Dr . Henderson reports Council
on Hormone Education (consultant); Dr. Pilkerton reports Duramed, Eli
Lilly, Merck, Procter & Gamble, Roche, Solvay (consultant), Berlex, Eli
Lilly, Pfizer/Alta, Procter & Gamble, Wyeth (speakers\' bureau), Eli
Lilly, Merck, Pfizer, Procter & Gamble, Solvay, Wyeth (research
support), Council on Hormone Education (executive committee); Dr. Reame
reports Procter & Gamble (consultant), Novo Nordisk, Procter & Gamble
(research support); Dr. Rothert reports no significant financial
relationships; Dr. Richardson reports Procter & Gamble (consultant); Dr.
Schiff reports Alliance for Better Bone Health, Medco, Pause, the
consumer magazine of the American College of Obstetricians and
Gynecologists (advisory board), Menopause, the official journal of The
North American Menopause Society (editor-in-chief); Dr. Speroff reports
Barr (consultant), Berlex, Organon, Wyeth (research support); Dr.
Stuenkel reports no significant financial relationships; Dr. Utian
reports Barr/Duramed, Berlex, Johnson & Johnson Pharmaceutical Research
and Development, Merck, Merrion, Novartis, Organon, Pfizer,
Roche/GlaxoSmithKline (consultant, advisory board), Amylin, 3M, Barr,
Berlex, Bristol- Myers Squibb, Duramed, Eli Lilly, Forest, Glen,
GlaxoSmithKline, Johnson & Johnson, Neurocrine Biosciences, Novartis,
Novo Nordisk, Organon, Pharmacia, Procter & Gamble, Pfizer, Roche,
Sepracor, Solvay, Wyeth, Yamanouchi (research support). For additional
contributors, Ms. Boggs, Dr. Graham, and Mr. Lammers all report no
significant financial relationships.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Management of postmenopausal
osteoporosis: position statement of the North American Menopause
Society. Menopause 2002 Mar-Apr;9(2):84-101.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from [The
North American Menopause Society (NAMS) Web
site](http://www.menopause.org/Portals/0/Content/PDF/psosteo06.pdf).

Print copies: Available from NAMS, P.O. Box 94527, Cleveland, OH 44101,
USA. Order forms are available in Portable Document Format (PDF) from
The North American Menopause Society (NAMS) Web site,
[www.menopause.org](http://www.menopause.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Key Points: NAMS 2006 position statement on management of
    postmenopausal osteoporosis. Slide set. 2006. 25 p. Available from
    [The North American Menopause Society (NAMS) Web
    site](http://www.menopause.org/Portals/0/Content/PDF/slidesPS_osteoporosis06.ppt).

-   NAMS continuing medical education activity. 2006. Available from
    [NAMS Web
    site](http://www.menopause.org/Portals/0/Content/PDF/psosteo06.pdf).

-   Boggs PP, Utian WH. The North American Menopause Society develops
    consensus opinions. Menopause 1998 Summer;5(2):67-8. Available from
    the [NAMS Web site](http://www.menopause.org/editorial.aspx).

Print copies: Available from NAMS, P.O. Box 94527, Cleveland, OH 44101,
USA. Order forms are available in Portable Document Format (PDF) from
The North American Menopause Society (NAMS) Web site,
[www.menopause.org](http://www.menopause.org/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on July 19, 2002. The information
was verified by the guideline developer on August 7, 2002. This NGC
summary was updated by ECRI on July 7, 2006. The updated information was
verified by the guideline developer on August 3, 2006.

#### COPYRIGHT STATEMENT

This summary is based on content contained in the original guideline,
which is subject to terms as specified by the guideline developer. Users
are free to download a copy of the materials and information on a single
computer for personal, noncommercial use only; provided that any
copyright, trademark or other proprietary notices are not removed from
any materials and information downloaded. Any other use requires written
permission from the guideline developer.

### DISCLAIMER

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Date Modified: 11/3/2008