[Therapeutic scheme of menopause: criteria of choice]

The treatment of menopause must meet efficacy, safety, simplicity and adaptability criteria. To achieve optimal benefit-to-risk ratio, treatment must be instituted and followed up with consideration to 1) the patient herself and 2) the type of treatment: molecule, dose, route of administration, sequence, duration, etc. The stage of menopause must be determined, since the deficiency, and hence replacement therapy, involves progestins in the years just before menopause, and estrogens in postmenopausal women. Cellular contra-indications (history of breast or endometrial cancer) concern all estrogens, whereas metabolic or thromboembolic contra-indications concern only oral estrogens. Which progestin? there is a consensus in favor of progesterone or one of its close derivatives (dydrogesterone, pregnane or norpregnane). Continuous or discontinuous treatment? Discontinuous treatment, closer to normal physiology, causes menstrual bleeding in 15 to 20% of patients, whereas continuous treatment, proposed to avoid menstruations, leads to irregular bleeding in 30 to 70% of the cases, bleeding which calls for additional and constraining investigations, and would be dangerous to ignore! Among the proposed formulations, the best will be the one which allows for individually tailored adjustment according to signs of estrogen overdosage or underdosage. Treatment may be instituted at any age of post-menopause, and need not be limited over time, unless a contra-indication develops.