What are the treatment options for menopause?

Treatment Options for Menopause

Menopausal hormone therapy (MHT) is the most effective treatment for menopausal symptoms, particularly vasomotor symptoms, and should be used at the lowest effective dose for the shortest duration needed. 1

Hormone Therapy Options

Estrogen-Based Therapies

• For women with an intact uterus: Combination estrogen and progestin therapy is required to prevent endometrial hyperplasia and cancer 1
• For women without a uterus: Estrogen-only therapy is preferred as it has a more favorable risk profile than combination therapy 1
• FDA-approved indications for conjugated estrogens include: 2
  • Treatment of moderate to severe vasomotor symptoms
  • Treatment of vulvar and vaginal atrophy
  • Prevention of postmenopausal osteoporosis

Timing and Duration Considerations

• Benefits typically exceed risks for symptomatic women under age 60 or within 10 years of menopause onset 3
• Combined estrogen/progestogen therapy may increase breast cancer risk when used for more than 3-5 years 4
• Cardiovascular risks (venous thromboembolism, stroke) may increase within the first 1-2 years of therapy 1

Non-Hormonal Treatment Options

For Vasomotor Symptoms

• Low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives to estrogen 4
• Vitamin E (800 IU/day) has modest effects on hot flashes 1

For Genitourinary Symptoms

• Vaginal estrogen (creams, rings, tablets) for vaginal dryness and dyspareunia 1
• Non-hormonal vaginal moisturizers 4
• Ospemifene - the only FDA-approved non-hormonal treatment for dyspareunia due to menopausal atrophy 4

Lifestyle Modifications

Daily Practices

• Maintain healthy weight and regular exercise 1, 5
• Avoid triggers and dress in layers to manage hot flashes 1
• Ensure adequate calcium (1500 mg/day) and vitamin D (400-800 IU/day) intake 1, 2

Nutritional Considerations

• Balanced diet with adequate protein intake 6
• Soy products may provide modest improvement in hot flashes and vaginal dryness 4

Treatment Algorithm

1. Assess symptom severity and type:

   • Vasomotor symptoms (hot flashes, night sweats)
   • Genitourinary symptoms (vaginal dryness, dyspareunia)
   • Sleep disturbances, mood changes, cognitive changes

2. Screen for contraindications to hormone therapy:

   • History of hormone-dependent cancers
   • Abnormal vaginal bleeding
   • Active liver disease
   • Recent pregnancy 1

3. For moderate to severe vasomotor symptoms:

   • First-line: MHT (if no contraindications)
   • Second-line: Non-hormonal medications (paroxetine, venlafaxine, gabapentin)

4. For genitourinary symptoms:

   • First-line: Vaginal estrogen preparations
   • Second-line: Non-hormonal vaginal moisturizers or ospemifene

5. For osteoporosis prevention:

   • Ensure adequate calcium and vitamin D
   • Weight-bearing exercise
   • Consider MHT when other options insufficient 2

Important Caveats

• Despite being effective, menopausal symptoms remain substantially undertreated 5
• The decision to use hormone therapy requires thorough evaluation of risks and benefits 4
• There is no high-quality evidence supporting yoga, acupuncture, black cohosh, botanical products, omega-3 fatty acids, or Chinese herbs beyond placebo effects 4
• Women will now live up to a third of their life being either peri- or postmenopausal, making effective management essential 7