From the Guidelines
Menopause is diagnosed primarily through clinical symptoms and confirmed by hormone testing, with treatment options including hormone replacement therapy (HRT) and non-hormonal alternatives, and should be individualized based on symptom severity, medical history, and personal preferences, with the lowest effective dose used for the shortest duration necessary to minimize risks. The diagnosis is typically made after 12 consecutive months without menstruation in women over 45 years old, accompanied by symptoms like hot flashes, night sweats, vaginal dryness, mood changes, and sleep disturbances. Blood tests showing elevated follicle-stimulating hormone (FSH) levels above 30 mIU/mL and low estradiol levels below 30 pg/mL can confirm the diagnosis, as noted in studies such as 1. Treatment options include hormone replacement therapy (HRT), which can be estrogen-only for women without a uterus or combined estrogen-progestin for those with a uterus. Common HRT formulations include oral estradiol (0.5-1mg daily), transdermal estradiol patches (0.025-0.1mg/day), and vaginal estrogen for localized symptoms. Non-hormonal options include selective serotonin reuptake inhibitors like paroxetine (7.5mg daily) or venlafaxine (75mg daily), gabapentin (300mg daily, increasing as needed), and clonidine (0.1mg twice daily), as discussed in 1. Lifestyle modifications such as regular exercise, maintaining healthy weight, avoiding triggers like caffeine and alcohol, and practicing relaxation techniques can help manage symptoms. It's essential to consider the potential risks and benefits of HRT, including the increased risk of stroke and venous thromboembolism, as well as the potential benefits of symptom relief and prevention of osteoporosis, as noted in studies such as 1. Ultimately, treatment should be tailored to the individual patient, taking into account their unique medical history, symptom severity, and personal preferences, with the goal of minimizing risks and maximizing benefits, as emphasized in 1.
From the FDA Drug Label
When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. For women who have a uterus, adequate diagnostic measures, such as endometrial sampling, when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding. 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.
The diagnostic criteria for menopause include:
- Undiagnosed persistent or recurring abnormal vaginal bleeding
- Vasomotor symptoms
- Vulval and vaginal atrophy
Treatment options for menopause include:
- Estrogen therapy: with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman
- Progestin therapy: to reduce the risk of endometrial cancer in women with a uterus
- Non-estrogen medications: for women at significant risk of osteoporosis
- Weight bearing exercise: to decrease the risk of postmenopausal osteoporosis
- Adequate calcium and vitamin D intake: to decrease the risk of postmenopausal osteoporosis 2 2
From the Research
Diagnostic Criteria for Menopause
- Menopause is typically diagnosed when a woman has not had a menstrual period for 12 consecutive months, and there are no other pathological or physiological causes for the cessation of menstruation 3.
- The average age of menopause is between 45 and 56 years, with the average age in the UK being 51 years 4.
- During the menopausal transition, women may experience various symptoms, including hot flashes, night sweats, and genitourinary symptoms, which can be chronic and last for several years 3.
Treatment Options for Menopause
- Hormonal therapy with estrogen is the first-line treatment for bothersome vasomotor symptoms and genitourinary syndrome of menopause (GSM) symptoms 3, 5.
- Systemic estrogen alone or combined with a progestogen can reduce the frequency of vasomotor symptoms by approximately 75% 3.
- Nonhormonal approaches, such as citalopram, desvenlafaxine, escitalopram, gabapentin, paroxetine, and venlafaxine, are available for women who are not candidates for hormonal treatments and can reduce the frequency of vasomotor symptoms by approximately 40% to 65% 3.
- Low-dose vaginal estrogen and vaginal prasterone can improve GSM symptom severity by approximately 60% to 80% and 40% to 80%, respectively 3.
- Progestin-only treatment may be effective for managing vasomotor symptoms in some women, but the optimal route and dosage have not been established 6.
Safety Considerations for Hormone Therapy
- Hormone therapy with estrogen and progestogen may increase the risk of breast cancer, stroke, and venous thromboembolism, particularly in older women 3, 7.
- Short-term use of hormone therapy (less than 5 years) in the years immediately after the onset of menopause may not be associated with an increased risk of these disorders 7.
- The risk-benefit ratio and safety profile of hormone therapy differ markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status 5.