From the Guidelines
The most effective treatment for post-menopausal symptoms is low-dose systemic hormone replacement therapy (HRT), which should be used at the lowest effective dose for the shortest time needed, usually reassessed annually. For women with moderate to severe symptoms, HRT typically involves using estradiol (0.5-1mg daily) combined with progesterone (100mg daily) for women with an intact uterus 1.
Non-Hormonal Options
For those unable to use hormonal options, selective serotonin reuptake inhibitors like paroxetine (7.5-25mg daily) or venlafaxine (37.5-150mg daily) can reduce hot flashes by 50-60% 1. Newer options include neurokinin B receptor antagonists like fezolinetant (45mg daily), recently approved for moderate to severe vasomotor symptoms.
Vaginal Symptoms
Vaginal symptoms respond well to local estrogen preparations (creams, rings, or tablets) with minimal systemic absorption. Complementary approaches like cognitive behavioral therapy, mindfulness, and paced respiration techniques have shown effectiveness for some women. These treatments work by addressing the hormonal changes that occur when ovarian function declines, particularly the drop in estrogen that affects temperature regulation, mood, and tissue integrity.
Additional Considerations
Other options for managing post-menopausal symptoms include pelvic physical therapy, vaginal dilators, and topical prescription medications such as vaginal estrogen and vaginal androgens (e.g., DHEA) 1. The choice of treatment should be individualized based on the specific symptoms and medical history of the patient.
Key Points
- Low-dose systemic HRT is the most effective treatment for post-menopausal symptoms
- Non-hormonal options like selective serotonin reuptake inhibitors and neurokinin B receptor antagonists can reduce hot flashes
- Local estrogen preparations can effectively manage vaginal symptoms
- Complementary approaches like cognitive behavioral therapy and mindfulness can be beneficial for some women
- Treatment should be individualized based on the specific symptoms and medical history of the patient.
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 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 latest treatment advances for managing post-menopausal symptoms include:
- Hormone replacement therapy (HRT) with estrogen, alone or in combination with a progestin, at the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman 2.
- Topical vaginal products should be considered when prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy 2.
- Non-estrogen medications should be considered for the prevention of postmenopausal osteoporosis, and estrogen therapy should only be considered for women at significant risk of osteoporosis and for whom non-estrogen medications are not considered to be appropriate 2.
- Lifestyle modifications, such as weight-bearing exercise, adequate calcium and vitamin D intake, may also be helpful in decreasing the risk of postmenopausal osteoporosis 2.
From the Research
Latest Treatment Advances for Post-Menopausal Symptoms
The latest treatment advances for managing post-menopausal symptoms include:
- Hormone Replacement Therapy (HRT) which is considered the gold standard for management of vasomotor and vaginal symptoms of menopause 3
- Low-dose HRT which has been shown to be safe and effective for prevention of postmenopausal bone loss and for reducing the number and severity of hot flashes 4
- Transdermal estrogen treatment which reduces the incidence and severity of hot flashes and is effective for protection against osteoporosis 4
- Combination of estrogen and progestogen for women with an intact uterus to reduce the risk of endometrial hyperplasia 5, 6
Key Considerations for HRT
Key considerations for HRT include:
- The type and dose of estrogen and progestogen used
- The route of administration (e.g. oral, transdermal, vaginal)
- The duration of treatment
- The individual patient's needs and medical history
- The potential risks and benefits of HRT, including the risk of endometrial hyperplasia, breast cancer, and cardiovascular disease 3, 5, 7
Alternative Therapies
Alternative therapies for post-menopausal symptoms include: