What are the treatment options for managing menopause symptoms?

From the Guidelines

Hormone replacement therapy (HRT) is the most effective treatment for managing menopause symptoms, and it should be used at the lowest effective dose for the shortest time needed, usually reassessed annually. Treatment options for managing menopause symptoms include both hormonal and non-hormonal approaches. HRT is typically used for vasomotor symptoms like hot flashes and night sweats, using estrogen alone (for women without a uterus) or estrogen plus progestin (for women with a uterus) 1. Common formulations include oral estradiol (0.5-1mg daily), transdermal patches (0.025-0.1mg/day), or vaginal estrogen for localized symptoms. For women who cannot or choose not to use hormones, several non-hormonal medications are effective, including certain antidepressants like venlafaxine (37.5-75mg daily) or paroxetine (7.5-25mg daily), gabapentin (300-900mg daily), or clonidine (0.1mg twice daily) 1. Lifestyle modifications can also help manage symptoms, including maintaining a healthy weight, regular exercise, avoiding trigger foods (spicy foods, caffeine, alcohol), dressing in layers, keeping the bedroom cool at night, and practicing stress reduction techniques like yoga or meditation. Some women find relief with complementary approaches such as black cohosh, though evidence for herbal remedies is limited. Vaginal moisturizers and lubricants can help with vaginal dryness and sexual discomfort. The choice of treatment should be individualized based on symptom severity, medical history, risk factors, and personal preferences.

Some key points to consider when managing menopause symptoms include:

• The use of HRT for the management of menopausal symptoms should be made on the basis of discussions between a woman and her clinician, taking into account the potential risks and benefits 1.
• The quality of evidence on the benefits and harms of HRT varies for different hormone regimens, and a cautious approach would be to avoid using HRT routinely for the specific purpose of preventing chronic disease in women 1.
• Estrogen transdermal formulations may be preferred over other formulations due to lower rates of venous thromboembolism (VTE) and stroke 1.
• Micronized progestin may be preferred over medroxyprogesterone acetate (MPA) due to lower rates of VTE and breast cancer risk 1.
• Custom compounded bioidentical hormones are not recommended because data supporting claims that they are safer and more effective than standard hormones are lacking 1.

Overall, the goal of managing menopause symptoms is to improve quality of life while minimizing the risks associated with treatment. By considering the individual needs and preferences of each woman, clinicians can provide personalized care that addresses the unique challenges of menopause.

From the FDA Drug Label

For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. Estradiol is used to: reduce moderate to severe hot flashes treat dryness, itching, and burning in or around the vagina, difficulty or burning on urination associated with menopause

The treatment options for managing menopause symptoms include:

• Hormone replacement therapy (HRT): Estradiol can be used to reduce moderate to severe hot flashes and treat dryness, itching, and burning in or around the vagina, difficulty or burning on urination associated with menopause 2 2.
• Lowest effective dose: The lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible 2.
• Regular evaluation: Patients should be reevaluated periodically (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary 2.
• Alternative treatments: Weight-bearing exercise, like walking or running, and taking calcium with vitamin D supplements may also lower the chances for getting postmenopausal osteoporosis 2.

From the Research

Treatment Options for Menopause Symptoms

The treatment options for managing menopause symptoms can be categorized into hormonal and nonhormonal approaches.

• Hormonal therapy with estrogen is the first-line therapy for bothersome vasomotor symptoms and genitourinary syndrome of menopause (GSM) symptoms 3.
• Systemic estrogen alone or combined with a progestogen reduces the frequency of vasomotor symptoms by approximately 75% 3.
• Nonhormonal approaches such as citalopram, desvenlafaxine, escitalopram, gabapentin, paroxetine, and venlafaxine are available and are associated with a reduction in frequency of vasomotor symptoms by approximately 40% to 65% 3.
• Low-dose vaginal estrogen is associated with subjective improvement in GSM symptom severity by approximately 60% to 80% 3.

Dietary Modifications and Supplements

Dietary modifications and food supplements may be explored by some women as alternatives to hormone replacement therapy.

• Soy isoflavones may reduce the frequency and/or severity of vasomotor symptoms, although results are inconsistent 4.
• Adopting a healthier dietary pattern may support a healthy bodyweight and benefit vasomotor symptoms 4.
• Some botanicals, such as black cohosh and St John's Wort, have been reported in some studies to alleviate symptoms, but these are not currently recommended due to uncertainty about the appropriate dose and preparation, and potential safety concerns 4.

Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a common treatment option for menopausal symptoms.

• The benefits of HRT in improving the symptoms of menopause are well-established, and it is currently estimated that approximately a million women in the UK are taking HRT for control of their menopausal symptoms 5.
• The type of progestin used in HRT is important regarding tolerance and cardiovascular and breast cancer risk, with micronized progesterone being considered a safer option than synthetic progestins 6.
• HRT is not indicated for the prevention of cardiovascular disease 3.

Alternative Therapies

Alternative therapies, such as selective serotonin reuptake inhibitors and phytoestrogens, may be used to treat vasomotor symptoms if contraindications present to hormone therapy or for those who prefer fewer side effects.

• These therapies may demonstrate symptom reduction in a large percentage of women, and understanding the pathophysiology, symptomatology, and current treatment options with side effect profiles allows for continued research and discovery of advanced therapy for treating symptoms 7.