What medications can be prescribed for menopause symptoms?

Medications for Menopause Symptoms

For menopause symptoms, first-line treatment should be non-hormonal options including low-dose antidepressants (SSRIs/SNRIs), anticonvulsants, and certain antihypertensives, while hormonal therapy can be considered after careful risk-benefit assessment. 1

Non-Hormonal Pharmacologic Options

First-Line Treatments

• SSRIs/SNRIs:

  • Paroxetine (7.5 mg daily) - reduces frequency and severity of hot flashes 1
  • Venlafaxine - faster effect than clonidine but less well tolerated 1
  • Citalopram, desvenlafaxine, escitalopram - reduce vasomotor symptoms by 40-65% 2

  Caution: Pure SSRIs, particularly paroxetine, should be used with caution in women taking tamoxifen due to CYP2D6 inhibition 1

• Anticonvulsants:

  • Gabapentin (900 mg/day) - can reduce hot flash severity by 46% 1
  • Pregabalin - improves menopause-related vasomotor symptoms 1
  • Particularly useful at bedtime for patients with sleep disturbances 1

• Antihypertensives:

  • Clonidine - reduces hot flash frequency and severity 1
  • Side effects include sleep difficulties, dry mouth, fatigue, dizziness, and nausea 1

Dosing Considerations

• Antidepressant doses for vasomotor symptoms are typically lower than those needed for depression 1
• Response is typically faster than when treating depression 1
• SNRIs and SSRIs should be gradually tapered when discontinuing to minimize withdrawal symptoms 1

Hormonal Therapy Options

Estrogen-Based Treatments

• Indications:

  • Moderate to severe vasomotor symptoms 3
  • Moderate to severe vulvar and vaginal atrophy 3
  • Hypoestrogenism due to hypogonadism, castration, or primary ovarian failure 3
  • Prevention of osteoporosis in women at significant risk 3

• Formulations:

  • Systemic estrogen (oral or transdermal) - reduces frequency of vasomotor symptoms by approximately 75% 2
  • Low-dose vaginal estrogen - improves genitourinary symptoms by 60-80% 2
  • For women with an intact uterus: combination with progestogen required to reduce endometrial cancer risk 2

Special Considerations

• Estrogen therapy is contraindicated in women with:
  • History of hormone-related cancers 1
  • History of abnormal vaginal bleeding 1
  • Active liver disease 1
  • Recent history of pregnancy 1

Treatment Algorithm

1. Initial Assessment:

   • Rule out medical causes of symptoms (thyroid disease, diabetes) 1
   • Laboratory evaluation: estradiol, FSH, LH, prolactin as clinically indicated 1

2. First-Line Treatment (Non-hormonal options):

   • For hot flashes: Start with SNRI/SSRI (venlafaxine or paroxetine) or gabapentin 1, 2
   • For vaginal dryness: Non-hormonal vaginal moisturizers 4

3. Second-Line Treatment (If first-line fails):

   • Consider hormonal therapy if no contraindications exist 1
   • For women with intact uterus: Combined estrogen/progestogen therapy 2
   • For women without uterus: Estrogen-only therapy 1
   • Use lowest effective dose for shortest duration possible 1

4. For Breast Cancer Survivors:

   • Avoid estrogen therapy due to increased risk of cancer recurrence 5
   • Use venlafaxine, paroxetine (if not on tamoxifen), or gabapentin 5

Common Pitfalls and Caveats

• FSH unreliability: FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation exposure, or in those on tamoxifen 1

• Tamoxifen interaction: Avoid paroxetine in women taking tamoxifen; consider alternative SSRIs/SNRIs 1

• Duration of therapy: Combined estrogen/progestogen therapy increases breast cancer risk when used for more than 3-5 years 4

• Bioidentical hormones: No data supports claims that custom-compounded bioidentical hormones are safer or more effective than standard hormone therapies 1

• Discontinuation: When stopping SNRIs/SSRIs, gradually taper to minimize withdrawal symptoms 1