What are the non-hormonal therapies for managing menopausal symptoms?

Non-Hormonal Therapies for Managing Menopausal Symptoms

Non-hormonal pharmacologic options should be used as first-line therapy for managing menopausal symptoms, particularly in women with contraindications to hormone therapy or those who prefer to avoid hormonal treatments. 1, 2

Pharmacologic Non-Hormonal Options

Antidepressants

• SSRIs and SNRIs:
  • Most effective non-hormonal options, reducing vasomotor symptoms by 40-65% 3
  • Paroxetine 7.5mg daily - FDA-approved specifically for menopausal vasomotor symptoms 4
  • Venlafaxine - Effective alternative, particularly for women on tamoxifen 2
  • Citalopram, Fluoxetine, Sertraline - Alternative options with varying efficacy 2

CAUTION: Paroxetine and other strong CYP2D6 inhibitors should be avoided in women taking tamoxifen due to potential interference with tamoxifen metabolism 1, 2

Anticonvulsants and Neuropathic Pain Relievers

• Gabapentin - Particularly effective for women with sleep disturbances; can reduce hot flash severity score by up to 46% 2
• Pregabalin - Alternative option in the same class 5

Antihypertensives

• Clonidine - Less preferred due to side effects (sleep difficulties, dry mouth, fatigue, dizziness) but may be considered for patients who cannot tolerate other options 2

Non-Pharmacologic Approaches

Lifestyle Modifications

• Avoiding triggers: spicy foods, caffeine, alcohol 2
• Environmental changes: cool rooms, dressing in layers 2
• Weight loss (10% or more can eliminate hot flash symptoms) 2
• Smoking cessation 2
• Regular physical activity 2

Complementary Approaches

• Acupuncture - Some studies show equivalence to or better results than drug treatments 2
• Cognitive Behavioral Therapy (CBT) - Can lessen perceived burden of hot flashes 2
• Relaxation techniques - Slow-breathing techniques and hypnosis have demonstrated clinical benefit 2
• Yoga - May improve quality of life associated with menopause 2

NOT RECOMMENDED: Black cohosh (reports of liver failure and lack of proven benefit) 2

Management Algorithm for Menopausal Symptoms

1. First-line therapy: Non-hormonal pharmacologic options

   • For vasomotor symptoms: Start with SSRI/SNRI (paroxetine 7.5mg daily or venlafaxine)
   • For women on tamoxifen: Avoid paroxetine, prefer venlafaxine
   • For predominant sleep disturbances: Consider gabapentin

2. If first-line therapy fails or is not tolerated:

   • Try alternative medication from a different class
   • Consider combination therapy with lifestyle modifications

3. For vaginal dryness:

   • Water-based lubricants and moisturizers as first-line treatment 2
   • Consider referral for pelvic evaluation to assess for vaginal atrophy 1

Special Considerations

• For cancer survivors: Non-hormonal options are strongly preferred, especially with hormone-sensitive cancers 1, 2
• For women with sleep disturbances: Gabapentin may be particularly beneficial 2
• For women with concurrent depression/anxiety: SSRIs/SNRIs may provide dual benefit 5

Side Effects to Monitor

• SSRIs/SNRIs: Nausea (37% with venlafaxine vs 11% placebo), dry mouth (22% vs 11%), dizziness (19% vs 7%), insomnia (18% vs 10%) 6
• Paroxetine: Dose-dependent side effects include nausea, fatigue, and dizziness 7, 4
• Gabapentin: Somnolence, dizziness, peripheral edema 5

Remember that doses of antidepressants required for improvements in vasomotor symptoms are typically much lower than those needed for depression, and the response is typically faster 1. This approach prioritizes treatments that have been shown to improve quality of life while minimizing risks associated with hormonal therapies.