What is an example prescription for a woman with menopausal symptoms?

Prescription for Menopausal Symptoms

For women with menopausal symptoms, the recommended first-line treatment is non-hormonal pharmacologic therapy, specifically SNRIs such as venlafaxine, which has been found to be safe and effective in reducing hot flashes. 1

Non-Hormonal Options (First-Line)

For Vasomotor Symptoms (Hot Flashes):

• Venlafaxine: 37.5-75 mg daily

  • Most effective SNRI with minimal drug interactions
  • Safe with tamoxifen (unlike paroxetine)
  • Reduces hot flash frequency by 40-65% 2

• Alternative options if venlafaxine is not tolerated:

  • Gabapentin: 300 mg at bedtime, increase to 300 mg three times daily as needed
  • Desvenlafaxine: 100 mg daily
  • Escitalopram: 10-20 mg daily

For Vaginal Symptoms:

• Non-hormonal vaginal moisturizers: Apply 3-4 times weekly
• Water or silicone-based lubricants for sexual activity (silicone-based products last longer) 1

Hormonal Options (Second-Line)

Consider only after non-hormonal options have failed and after careful risk assessment:

For women WITHOUT history of hormone-sensitive cancers:

• Transdermal estradiol patch: 0.025-0.0375 mg/day 3

  • Lower risk of venous thromboembolism than oral formulations
  • Adjust dose based on symptom control

• For women with intact uterus, add:

  • Micronized progesterone: 200 mg orally for 12-14 days per month 3

Important Contraindications for Hormonal Therapy:

• History of hormone-related cancers
• History of abnormal vaginal bleeding
• Active liver disease
• Recent history of venous thromboembolism or stroke 1, 3

Special Considerations

For Breast Cancer Survivors:

• Systemic hormone therapy is generally not recommended 1
• Low-dose vaginal estrogen tablets or estradiol vaginal ring may be considered for severe vaginal symptoms, but safety is not well established 1
• Avoid hormonal therapies in women on aromatase inhibitors 1

For Sexual Dysfunction:

• Consider vaginal dilators for dyspareunia secondary to vaginal atrophy
• Referral for psychoeducational support, sexual counseling, or marital counseling 1

Lifestyle Modifications (Adjunctive)

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

Monitoring and Follow-up

• Initial follow-up at 3-6 months
• Assess symptom improvement and side effects
• Adjust therapy as needed, using lowest effective dose for shortest duration 3

Important Caveats

• When using SSRIs/SNRIs with tamoxifen, avoid paroxetine as it inhibits CYP2D6 and may reduce tamoxifen's effectiveness 1
• For women with history of breast cancer, the decision to use any form of hormonal therapy should involve careful consideration of risks and benefits, with full patient information about potential adverse effects on disease prognosis 1

This prescription approach prioritizes safety while addressing quality of life concerns, with non-hormonal options as first-line therapy and careful consideration of hormonal options only when necessary and appropriate.