Management of Postmenopausal Symptoms
For most women experiencing postmenopausal symptoms, non-hormonal approaches should be tried first, followed by hormonal therapy only if symptoms remain disruptive to quality of life after weighing individual risks and benefits. 1
Assessment of Postmenopausal Symptoms
Before initiating treatment, assess for:
- Severity and type of symptoms (vasomotor, genitourinary, sleep disturbances)
- Medical history (breast cancer, cardiovascular disease, thromboembolic events)
- Laboratory evaluation (estradiol, FSH, LH, prolactin) as clinically indicated 1
- For vaginal dryness, perform pelvic evaluation to assess for vaginal atrophy 1
Treatment Options
1. Vasomotor Symptoms (Hot Flashes)
Non-Hormonal Pharmacologic Options (First-Line)
- SSRIs/SNRIs: Low-dose antidepressants (lower doses than needed for depression) 1
- Paroxetine 7.5mg daily (caution with tamoxifen due to CYP2D6 inhibition)
- Venlafaxine
- Anticonvulsants:
- Gabapentin
- Pregabalin
- Other options:
- Clonidine
- Oxybutynin 1
Lifestyle Modifications
- Weight loss (≥10% of body weight may help eliminate hot flashes) 1
- Smoking cessation (improves frequency and severity of hot flashes) 1
- Limit alcohol if it triggers symptoms 1
- Cognitive behavioral therapy (CBT) 1
Hormonal Therapy (If Non-Hormonal Options Fail)
- For women with intact uterus: Estrogen plus progestin 2
- Starting dose: 1-2mg daily of estradiol, adjusted as necessary
- Cyclic administration (3 weeks on, 1 week off)
- For women without uterus: Estrogen alone 2
- Starting dose: 1-2mg daily of estradiol
- Use lowest effective dose for shortest duration 2
- Transdermal estrogen preferred over oral (lower VTE and stroke risk) 1
- Reevaluate every 3-6 months 2
2. Vaginal Dryness and Atrophy
Non-Hormonal Options (First-Line)
- Over-the-counter vaginal moisturizers and lubricants 1
- Water-based gels, hyaluronic acid gel 1
- Topical vitamin D or E 1
Hormonal Options
- Local vaginal estrogen preparations (rings, suppositories, creams) 1
- Lower systemic absorption than oral/transdermal
- May be safer option for women with contraindications to systemic HRT
3. Sexual Dysfunction
- Address vaginal dryness first (see above)
- Consider referral to specialist for complex cases 1
Special Considerations
Contraindications to Hormonal Therapy
- History of hormonally mediated cancers
- Active or recent thromboembolic events
- Abnormal vaginal bleeding
- Active liver disease
- Pregnancy 1
Use with Caution
- Coronary heart disease
- Hypertension
- Current smokers
- Increased genetic cancer risk 1
Risks of Hormone Therapy
Based on Women's Health Initiative (WHI) data, per 10,000 women taking estrogen and progestin for 1 year 1:
- 7 additional CHD events
- 8 more strokes
- 8 more pulmonary emboli
- 8 more invasive breast cancers
- 6 fewer cases of colorectal cancer
- 5 fewer hip fractures
Follow-up
- Reevaluate every 3-6 months to determine if treatment is still necessary 2
- For women on hormonal therapy, attempt to discontinue or taper medication at 3-6 month intervals 2
- Monitor for adverse effects based on therapy chosen
Alternative Therapies
- Acupuncture may help with vasomotor symptoms 3
- Evidence for phytoestrogens (soy products) is inconclusive 1
- Chinese herbal medicines may help alleviate symptoms but require more standardized evaluation 4, 3
Remember that the absolute increase in risk from hormone therapy is modest, and some women, depending on their risk characteristics and personal preferences, might decide that the benefits outweigh the potential harms 1.