What are the treatment options for menopausal symptoms?

Treatment Options for Menopausal Symptoms

For most women experiencing menopausal symptoms, non-hormonal treatments should be first-line therapy, with hormone replacement therapy (HRT) reserved for severe symptoms and used at the lowest effective dose for the shortest possible duration due to significant associated risks.

Assessment of Menopausal Symptoms

When evaluating menopausal symptoms, consider:

• Severity and impact on quality of life
• Specific symptom profile (vasomotor, genitourinary, mood, sleep, etc.)
• Age and time since menopause
• Presence of contraindications to hormone therapy
• Personal risk factors for breast cancer, cardiovascular disease, and thromboembolism

Non-Hormonal Treatment Options

For Vasomotor Symptoms (Hot Flashes/Night Sweats)

1. Pharmacologic options:

   • SSRIs/SNRIs: Low-dose paroxetine (7.5 mg daily) or venlafaxine 1
   • Gabapentin 2
   • Note: Paroxetine should be used with caution in women taking tamoxifen due to CYP2D6 inhibition 1

2. Non-pharmacologic approaches:

   • Lifestyle modifications: Layered clothing, avoiding triggers (alcohol, spicy foods, caffeine)
   • Temperature control in the environment
   • Clinical hypnosis may provide modest benefit 2

For Genitourinary Symptoms

1. Vaginal dryness/atrophy:

   • Non-hormonal vaginal moisturizers
   • Ospemifene (for dyspareunia due to menopausal atrophy) 2
   • Regular sexual activity

2. Urinary symptoms:

   • Pelvic floor exercises
   • Bladder training

Hormone Replacement Therapy (HRT)

HRT should be considered when:

• Symptoms are moderate to severe
• Non-hormonal treatments have failed
• Benefits outweigh risks for the individual patient

Types of HRT

1. For women with an intact uterus:

   • Combined estrogen and progestogen therapy is required to prevent endometrial cancer 3, 4
   • Typical regimen: Conjugated equine estrogen (0.625 mg/day) with medroxyprogesterone acetate (2.5-10 mg/day) 3, 4

2. For women without a uterus:

   • Estrogen-only therapy 3

3. Alternative formulations:

   • Transdermal estrogen (preferred due to lower VTE risk) 3
   • Combined estrogen with bazedoxifene (for women who cannot tolerate progestogens) 2
   • Vaginal estrogen for isolated genitourinary symptoms 1

Risks of HRT

HRT is associated with significant risks that must be considered:

• Estrogen plus progestin increases risk of:

  • Breast cancer (8 additional cases per 10,000 women-years) 3
  • Stroke (8 additional strokes per 10,000 women-years) 3
  • Venous thromboembolism 3
  • Gallbladder disease (20 additional cases per 10,000 women-years) 1
  • Dementia (22 additional cases per 10,000 women-years) 1
  • Urinary incontinence (872 additional cases per 10,000 women-years) 1

• Estrogen-only therapy increases risk of:

  • Stroke (11 additional strokes per 10,000 women-years) 1
  • Deep venous thrombosis (7 additional cases per 10,000 women-years) 1
  • Gallbladder disease (33 additional cases per 10,000 women-years) 1
  • Urinary incontinence (1271 additional cases per 10,000 women-years) 1

Contraindications to HRT

Absolute contraindications include:

• History of hormone-dependent cancers
• History of venous thromboembolism
• Active liver disease
• Unexplained vaginal bleeding
• History of stroke or coronary heart disease 1, 3

Special Considerations

For Young Women with Premature Menopause

• HRT may be beneficial until the average age of natural menopause
• Benefits typically outweigh risks for cardiovascular and bone protection 3
• Consider transdermal estradiol for potentially lower VTE risk 3

For Cancer Survivors

• Non-hormonal options are preferred for breast cancer survivors 1
• Estrogen replacement is controversial even in women with hormone receptor-negative breast cancer 1
• For young patients with non-breast cancers who experience chemotherapy-induced premature menopause, estrogen may be considered for symptom relief and bone health 1

Treatment Algorithm

1. Assess symptom severity and impact on quality of life
2. Screen for contraindications to HRT
3. For mild symptoms:
   • Begin with lifestyle modifications and non-hormonal approaches
4. For moderate to severe vasomotor symptoms without contraindications:
   • Consider low-dose HRT for shortest duration possible (typically 2-5 years)
   • Use transdermal formulations when possible to reduce VTE risk
   • Include progestogen if uterus is intact
5. For isolated genitourinary symptoms:
   • Consider vaginal estrogen or non-hormonal moisturizers
6. Monitor regularly:
   • Reassess symptoms, side effects, and continued need for therapy annually
   • Consider discontinuation or dose reduction after 2-5 years

Key Pitfalls to Avoid

1. Using HRT for prevention of chronic conditions rather than symptom management
2. Prescribing estrogen alone to women with an intact uterus
3. Failing to recognize contraindications to HRT
4. Not discussing the risks and benefits of therapy with patients
5. Continuing HRT longer than necessary for symptom control

Remember that HRT decisions should prioritize morbidity, mortality, and quality of life outcomes, with the goal of using the lowest effective dose for the shortest duration necessary to control symptoms.