From the Guidelines
Vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women, and has been shown to be effective in treating itching, discomfort, and painful intercourse. For women with postmenopausal symptoms, particularly vaginal dryness and sexual dysfunction, treatment options include:
- Vaginal estrogen preparations, such as creams, tablets, or rings, which can be used without systemic effects 1
- Topical prescription medications, such as intravaginal testosterone cream or an estradiol-releasing vaginal ring, which have been shown to be safe and effective in improving vaginal atrophy and sexual function in postmenopausal women with hormone receptor-positive breast cancer receiving aromatase inhibitor therapy 1
- Vaginal androgens, such as DHEA, which can be considered for vaginal dryness or pain with sexual activity, although safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers are limited 1
- Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), which has been studied in several large trials of individuals with postmenopausal vulvar and vaginal atrophy and was found to effectively treat vaginal dryness and dyspareunia 1
- Flibanserin, an FDA-approved medication used to treat acquired, generalized hypoactive sexual desire disorder, which is also an option for survivors 1
- Pelvic physical therapy, such as pelvic floor muscle training, which can be used to treat pelvic floor dysfunction and improve sexual function 1
- Vaginal dilators, which can be used to increase vaginal depth and accommodation and may allow a survivor to discover what hurts and what does not in a nonsexual setting 1
It is essential to note that the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers, and therefore, should be used with caution in these patients 1. Additionally, lifestyle modifications, such as maintaining a healthy weight, quitting smoking, and limiting alcohol intake, may also help alleviate postmenopausal symptoms 1. Cognitive behavioral therapy (CBT) may also be effective in reducing vasomotor symptoms in postmenopausal women 1.
From the FDA Drug Label
Progesterone capsules are used for the treatment of secondary amenorrhea (absence of menstrual periods in women who have previously had a menstrual period) due to a decrease in progesterone Progesterone capsules are used in combination with estrogen-containing medications in a postmenopausal woman with a uterus (womb). A postmenopausal woman with a uterus who is taking estrogens should take a single daily dose of 200 mg progesterone capsules at bedtime for 12 continuous days per 28-day cycle.
The treatment options for postmenopausal symptoms include:
- Hormone therapy: Progesterone capsules in combination with estrogen-containing medications to reduce the chance of getting cancer of the uterus (womb) 2
- Progesterone capsules: To provide the progesterone needed for women who do not produce enough progesterone on their own, which can help with menstrual irregularities 2 Key points to consider:
- Progesterone capsules should be taken as a single daily dose at bedtime
- Women with a uterus who are taking estrogens should take progesterone capsules for 12 continuous days per 28-day cycle
- Progesterone capsules may cause side effects such as dizziness, drowsiness, and abdominal cramps 2
From the Research
Treatment Options for Postmenopausal Symptoms
The treatment options for postmenopausal symptoms include:
- Hormonal therapy (HT) which is still the most effective treatment with safety in early initiation since menopause onset 3
- Non-hormonal therapy (non-HT) which includes fezolinetant, ospemifene, dehydroepiandrosterone (DHEA), and vaginal lasers 3
- Conjugated estrogens (CE) combined with the selective estrogen receptor modulator bazedoxifene (BZA) which is a new progestin-free HT option for alleviating estrogen deficiency symptoms in postmenopausal women with a uterus 4
- Transdermal and vaginal HT which may have a lower risk 5
- Oral HT formulations which have additional clinical benefits in relieving vasomotor symptoms and preventing osteoporosis 5
- Chinese herbal medicines which have benefits in alleviating hot flashes, depression, and menopausal symptoms 5
- Acupuncture and electroacupuncture which have definite efficacy in the treatment of postmenopausal symptoms with few adverse effects 5
- Hormone replacement therapy (HRT) which is considered the gold standard for management of vasomotor and vaginal symptoms of menopause 6
Considerations for Hormone Replacement Therapy (HRT)
When considering HRT, the following factors should be taken into account:
- Cyclic vs continuous administration 6
- Tapering therapy 6
- Estrogen dosage forms including injections and transdermal formulations 6
- Combination of estrogen with progestin or bazedoxifene for women with an intact uterus 6
- Patient's age, associated diseases, and duration of treatment 7
- Genetic screening to maximize the ratio between positive and adverse effects 7
Risks and Benefits of HRT
The risks and benefits of HRT should be carefully evaluated, including: