What are the treatment options for menopausal symptoms?

Treatment Options for Menopausal Symptoms

Menopausal hormone therapy (MHT) is the most effective treatment for managing vasomotor symptoms and vaginal atrophy, but should be used at the lowest effective dose for the shortest duration needed to control symptoms due to associated risks.

First-Line Approaches

Non-Hormonal Options

• Lifestyle modifications:
  • Regular aerobic and resistance exercise programs
  • Weight loss for women with elevated BMI
  • Healthy calorie-restricted diet
  • Calcium and vitamin D supplementation
  • Weight-bearing exercise

Non-Hormonal Pharmacologic Treatments

• For vasomotor symptoms:

  • SSRIs/SNRIs (e.g., paroxetine, venlafaxine)
  • Gabapentin
  • Clonidine
  • Low-dose paroxetine (FDA-approved for hot flashes)

• For vaginal symptoms:

  • Vaginal moisturizers and lubricants (first-line)
  • Ospemifene (FDA-approved for dyspareunia due to vaginal atrophy)

Hormone Therapy Options

For Women with an Intact Uterus

• Combined estrogen and progestogen therapy is required 1
  • Prevents increased risk of endometrial cancer from unopposed estrogen
  • Options include:
    • Sequential regimen: Estrogen daily with progestogen 12-14 days per month
      • Progesterone options: 200 mg oral/vaginal micronized progesterone or 10 mg medroxyprogesterone acetate
    • Continuous combined regimen: Daily estrogen and progestogen
      • Minimum 2.5 mg oral medroxyprogesterone acetate daily

For Women Without a Uterus

• Estrogen-only therapy 1, 2
  • Typically estradiol 1-2 mg daily

Estrogen Formulations

• Oral estradiol: 1-2 mg daily
• Transdermal estradiol: 0.025-0.0375 mg/day patch
• Conjugated equine estrogen: 0.625 mg/day

Local Vaginal Estrogen for Genitourinary Symptoms

• Rings
• Suppositories
• Creams
• Lower systemic absorption than oral/transdermal formulations

Risk Considerations and Monitoring

Risks of Hormone Therapy

• Breast cancer (increased risk with combined therapy used >3-5 years) 1, 3
• Venous thromboembolism (RR 2.14) 1
• Stroke (RR 1.12) 1
• Gallbladder disease (RR 1.8-2.5) 1
• Urinary incontinence 1

Absolute Contraindications

• History of hormone-dependent cancers 4, 1
• Breast or uterine cancer 1
• Abnormal vaginal bleeding (undiagnosed) 2
• Active liver disease 4, 2
• Recent history of or active venous thromboembolism 1
• Recent stroke or heart attack 2

Monitoring and Follow-up

• Initial follow-up: 8-10 weeks after treatment initiation
• Regular reassessment: Every 3-6 months 1, 2
• Annual comprehensive assessment of risks and benefits
• For women with a uterus: Appropriate diagnostic measures (e.g., endometrial sampling) for abnormal vaginal bleeding 2

Special Considerations

Age and Timing

• Most favorable benefit-risk ratio when started in early menopause (within 10 years of menopause or before age 60) 5
• Women experiencing early menopause may benefit from oral contraceptives for symptom relief 4

Route of Administration

• Transdermal estrogen may have lower thrombotic risk than oral formulations 1, 6
• Micronized progesterone is associated with lower cardiovascular and thrombotic risk than synthetic progestins 1

Duration of Treatment

• Attempt to discontinue or taper medication at 3-6 month intervals 2
• Reassess need for continued therapy regularly 1, 2

Practical Algorithm for Treatment Selection

1. Assess symptom severity and impact on quality of life
2. Rule out contraindications to hormone therapy
3. For mild symptoms: Start with lifestyle modifications and non-hormonal approaches
4. For moderate to severe vasomotor symptoms:
   • If no contraindications: Consider MHT
   • If contraindicated: Use non-hormonal pharmacologic options
5. For vaginal symptoms only: Consider local vaginal estrogen
6. For women with an intact uterus: Always combine estrogen with progestogen
7. Start with lowest effective dose and reassess regularly

Remember that the decision to use hormone therapy should be based on symptom severity, medical history, and a thorough discussion of risks and benefits with your healthcare provider.