From the Guidelines
Hormone therapy, specifically estrogen alone or estrogen plus progestogen, is the most effective treatment option for menopausal symptoms, reducing hot flashes by 75-80%. For women with moderate to severe vasomotor symptoms, hormone therapy is recommended as the first line of treatment 1. The treatment should use the lowest effective dose for the shortest duration needed, typically reassessing after 3-5 years. 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.
For women who cannot or prefer not to use hormonal therapy, several non-hormonal options exist, including:
- Selective serotonin reuptake inhibitors (SSRIs) like paroxetine (7.5-25 mg daily) or escitalopram (10-20 mg daily)
- The serotonin-norepinephrine reuptake inhibitor venlafaxine (37.5-150 mg daily)
- Gabapentin (300-900 mg daily)
- Clonidine (0.1-0.2 mg daily) 1 These medications work by affecting neurotransmitters involved in temperature regulation.
Lifestyle modifications can also help, including:
- Maintaining a cool environment
- Wearing layered clothing
- Avoiding triggers like alcohol and spicy foods
- Practicing stress reduction techniques
- Regular exercise
- Maintaining a healthy weight
- Avoiding smoking 1
Vaginal symptoms can be treated with local estrogen preparations (creams, tablets, or rings) that have minimal systemic absorption 1. Over-the-counter vaginal moisturizers, gels, oils, and topicals can also be used for comfort and topical vitamin D or E 1. Lubricants can be used for sexual activity 1.
It's essential to note that hormone therapy is contraindicated in survivors with a history of hormonally mediated cancers, and alternatives to hormone therapy should typically be tried first 1. Patients should be referred to an appropriate specialist for dosing and management of hormone therapy 1.
From the Research
Treatment Options for Menopausal Symptoms
The treatment options for menopausal symptoms can be categorized into hormonal and non-hormonal therapies.
- Hormonal therapies, such as estrogen-based therapies, are considered the most effective treatments for many menopausal symptoms 2.
- Non-hormonal treatment options are also available, including lifestyle modifications, diet and food supplements, non-hormonal medications, and behavioral and alternative medicine therapies 3.
Hormonal Therapies
Hormonal therapies, including unopposed estrogen and estrogen/progestogen combinations, are effective treatments for menopausal symptoms but are associated with risks of harms 4, 5.
- For women with a uterus, hormone therapy should comprise both estrogen and progestogen to reduce the risk of endometrial hyperplasia 4, 5.
- The risk of endometrial hyperplasia with hormone therapy comprising low-dose estrogen continuously combined with a minimum of 1 mg norethisterone acetate or 1.5 mg medroxyprogesterone acetate is not significantly different from placebo 4, 5.
Non-Hormonal Therapies
Non-hormonal therapies, such as selective serotonin-reuptake inhibitors (SSRIs), serotonin norepinephrine-reuptake inhibitors (SNRIs), and gabapentin, can be proposed as alternatives to hormonal therapies for menopausal symptoms 3.
- Lifestyle modifications, diet and food supplements, and behavioral and alternative medicine therapies may also be used to manage menopausal symptoms, although the evidence for their effectiveness is limited 6, 3.
- Physical activity, diet supplements, body work, and mind-body techniques are often used by women to manage menopausal symptoms, but their safety and effectiveness need to be evaluated 6.