What medications are used to treat menopause symptoms?

Medications for Menopause Symptoms

For menopausal symptoms, first-line treatment should include nonhormonal options such as SNRIs, SSRIs, gabapentin, and lifestyle modifications, with hormonal therapy reserved for those without contraindications who have persistent symptoms. 1

Vasomotor Symptoms (Hot Flashes/Night Sweats)

Nonhormonal Pharmacologic Options (First-Line)

• SNRIs/SSRIs:

  • Venlafaxine (SNRI): Safe and effective for reducing hot flashes 1
  • Paroxetine (SSRI): Use with caution in women taking tamoxifen due to CYP2D6 inhibition 1
  • Typically require lower doses than those used for depression 1

• Anticonvulsants:

  • Gabapentin: Effective for reducing hot flash frequency and severity 1
  • Pregabalin: Alternative option with similar efficacy 1

• Other medications:

  • Clonidine (antihypertensive): Used clinically for hot flashes 1

Hormonal Options (Second-Line)

• Estrogen therapy: Most effective treatment for vasomotor symptoms 2, 3
  • For women with intact uterus: Must combine with progestin to prevent endometrial cancer 1, 2
  • For women without uterus: Estrogen alone 1
  • Contraindicated in women with history of hormone-dependent cancers 1
  • Formulations include oral tablets, transdermal patches, gels, and sprays 2

Vaginal/Urogenital Symptoms

Nonhormonal Options (First-Line)

• Vaginal moisturizers and lubricants:

  • Water-based or silicone-based products 1
  • Silicone-based products may last longer than water-based products 1
  • Can be used in combination for additional comfort 1

• Ospemifene: FDA-approved nonhormonal treatment for dyspareunia due to menopausal atrophy 4

Hormonal Options (Second-Line)

• Local estrogen therapy:
  • Vaginal tablets, creams, or rings 1
  • Takes 6-12 weeks for full effect 1
  • May be used cautiously in women with breast cancer history, though safety not well established 1
  • Not recommended for women on aromatase inhibitors 1

Special Considerations

Breast Cancer Survivors

• Avoid systemic hormone therapy 1, 5
• Preferred options:
  • SNRIs (venlafaxine preferred) 1
  • SSRIs (avoid paroxetine with tamoxifen) 1
  • Gabapentin 1
  • Nonhormonal vaginal moisturizers for vaginal symptoms 1

Complementary Approaches

• Lifestyle modifications:

  • Environmental modifications (cool rooms, dressing in layers) 1
  • Avoiding triggers (spicy foods, caffeine, alcohol) 1
  • Regular exercise 1
  • Rhythmic breathing techniques 1

• Other therapies with some evidence:

  • Acupuncture: Shown to reduce menopausal symptoms in meta-analysis 1
  • Soy products: Modest improvement in hot flashes and vaginal dryness 4
  • Clinical hypnosis: May significantly reduce hot flashes 4

Treatment Algorithm

1. Assess symptom severity and impact on quality of life
2. Rule out other medical causes (thyroid disease, diabetes) 1
3. For vasomotor symptoms:
   • Start with nonhormonal options (SNRIs/SSRIs, gabapentin) and lifestyle modifications
   • If inadequate relief and no contraindications, consider hormone therapy
4. For vaginal symptoms:
   • Start with nonhormonal moisturizers and lubricants
   • If inadequate relief, consider local vaginal estrogen (if no contraindications)

Common Pitfalls to Avoid

• Using systemic hormone therapy in women with history of breast cancer 1, 5
• Prescribing estrogen alone in women with intact uterus (increases endometrial cancer risk) 1
• Using paroxetine in women taking tamoxifen (may reduce tamoxifen efficacy) 1
• Continuing hormone therapy longer than necessary (increased breast cancer risk with combined therapy used >3-5 years) 4
• Overlooking nonpharmacological approaches that may provide significant relief 1

Remember that menopausal symptoms can persist for more than a decade, with genitourinary symptoms typically being progressive 6. Timely and appropriate treatment can significantly improve quality of life during this transition.