What are the treatment options for menopause?

Treatment Options for Menopause

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms and other symptoms of menopause, with benefits generally exceeding risks for most symptomatic women under age 60 or within 10 years of menopause onset. 1

Assessment of Menopausal Symptoms

Menopausal symptoms can significantly impact quality of life and include:

• Vasomotor symptoms (hot flashes, night sweats)
• Genitourinary symptoms (vaginal dryness, dyspareunia)
• Sleep disturbances
• Mood changes
• Cognitive changes
• Sexual dysfunction
• Bone density loss
• Metabolic changes

Hormone Therapy Options

For Women with an Intact Uterus:

• Combination estrogen and progestin therapy 2
  • Prevents endometrial hyperplasia and cancer risk
  • Use lowest effective dose for shortest duration needed

For Women without a Uterus:

• Estrogen-only therapy 2
  • Avoids unnecessary progestin exposure
  • More favorable risk profile than combination therapy

FDA-Approved Indications for Hormone Therapy:

• Treatment of moderate to severe vasomotor symptoms
• Treatment of moderate to severe vulvar and vaginal atrophy
• Prevention of postmenopausal osteoporosis 3

Non-Hormonal Pharmacologic Options

For women with contraindications to hormone therapy or who prefer non-hormonal approaches:

• Antidepressants:

  • Low-dose paroxetine (FDA-approved for hot flashes)
  • Venlafaxine 4

• Anticonvulsants:

  • Gabapentin - effective for hot flashes 4

• Other medications:

  • Clonidine
  • Vitamin E (modest effect at 800 IU/day) 2

Local Treatments for Genitourinary Symptoms

• Vaginal estrogen (creams, rings, tablets) - effective for vaginal dryness and dyspareunia 2
• Ospemifene - non-hormonal option FDA-approved for dyspareunia 4
• Vaginal moisturizers and lubricants - for those who cannot use hormonal options 4

Lifestyle and Complementary Approaches

• Lifestyle modifications:

  • Dressing in layers
  • Avoiding triggers (spicy foods, alcohol, caffeine)
  • Maintaining healthy weight
  • Regular exercise 2
  • Adequate calcium (1500 mg/day) and vitamin D (400-800 IU/day) intake 3

• Complementary approaches (limited evidence):

  • Acupuncture - mixed results
  • Clinical hypnosis - some evidence for hot flash reduction 4
  • Soy products - modest improvement in hot flashes and vaginal dryness 4

Treatment Algorithm

1. Assess symptom severity and impact on quality of life
2. Rule out medical causes (thyroid disease, diabetes)
3. For moderate to severe vasomotor symptoms:
   • If no contraindications: MHT is first-line therapy
   • If contraindicated: Non-hormonal options (SSRIs, gabapentin)
4. For genitourinary symptoms:
   • Vaginal estrogen or ospemifene
   • Non-hormonal moisturizers and lubricants

Important Considerations and Cautions

• Duration of therapy: Use lowest effective dose for shortest duration needed 2
• Timing matters: Benefits generally exceed risks for women under age 60 or within 10 years of menopause onset 1
• Breast cancer risk: Combined estrogen/progestogen therapy increases risk when used for more than 3-5 years 4
• Cardiovascular risk: Some risks (venous thromboembolism, stroke) may increase within first 1-2 years of therapy 2
• Contraindications to MHT:
  • History of hormone-dependent cancers
  • History of abnormal vaginal bleeding
  • Active liver disease
  • Recent pregnancy 2

Follow-up and Monitoring

• Review effectiveness and side effects after 4-6 weeks of treatment
• Attempt to discontinue or reduce therapy annually to assess if symptoms persist
• For women on MHT, regular breast cancer screening is essential

MHT remains the most effective treatment for menopausal symptoms, but treatment decisions should be based on symptom severity, medical history, and patient preferences, with careful consideration of risks and benefits.