From the Guidelines
Hormone replacement therapy (HRT) should not be considered as a first-line treatment for women more than 10 years post-menopause for the treatment of vasomotor symptoms due to increased risks, but may be considered for severe symptoms at the lowest effective dose for the shortest duration possible. For these women, standard HRT options include estrogen-only therapy (for women without a uterus) such as oral estradiol 0.5-1mg daily, transdermal estradiol patch 0.025-0.05mg/day, or vaginal estradiol ring; or combined estrogen-progestogen therapy (for women with an intact uterus) such as oral estradiol 0.5-1mg daily plus micronized progesterone 100-200mg daily or medroxyprogesterone acetate 2.5-5mg daily.
Key Considerations
- Treatment should begin with lower doses and be titrated based on symptom response.
- Women should be thoroughly evaluated for cardiovascular and breast cancer risk factors before initiating therapy, as the risk-benefit ratio becomes less favorable with increasing time from menopause.
- Regular follow-up every 6-12 months is essential to reassess the need for continued therapy.
- The mechanism of action involves replacing declining estrogen levels, which helps regulate the hypothalamic temperature control center and reduce vasomotor symptoms.
- Non-hormonal alternatives like selective serotonin reuptake inhibitors, gabapentin, or lifestyle modifications should be considered first in this population due to their more favorable risk profile, as suggested by 1.
Alternatives to HRT
- Selective serotonin reuptake inhibitors
- Gabapentin
- Lifestyle modifications It is essential to weigh the benefits and risks of HRT in this population, considering the increased risks of breast cancer and cardiovascular and thromboembolic morbidity associated with prolonged HRT use, as noted in 1.
From the Research
Role of Hormone Replacement Therapy (HRT) in Women More Than 10 Years Post-Menopause
- Hormone Replacement Therapy (HRT) is considered the most effective treatment for vasomotor symptoms in post-menopausal women 2, 3.
- However, when initiating or continuing HRT in women more than 10 years post-menopause, clinicians should consider factors such as cardiovascular disease risk, breast cancer risk, and osteoporosis risk 2.
- A shared decision-making approach is recommended to support women in managing their menopausal symptoms and maintaining their health and quality of life 2, 4.
Alternatives to HRT for Vasomotor Symptoms
- Non-hormonal treatment options, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), can be effective in reducing vasomotor symptoms in women who cannot or choose not to use HRT 3, 5, 4, 6.
- Paroxetine is the only non-hormonal treatment approved by the US FDA for the management of moderate to severe postmenopausal vasomotor symptoms, and it is recommended to be taken at a dose of 7.5 mg once daily at bedtime 5.
- Other emerging treatments for vasomotor symptoms include estetrol, oxybutynin, and neurokinin 3 (NK3) receptor antagonists 5, 6.