What are the treatment options for menopause?

Treatment Options for Menopause

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms of menopause, but should only be used for symptom management rather than prevention of chronic conditions, with the lowest effective dose for the shortest possible duration. 1

Vasomotor Symptoms (Hot Flashes/Night Sweats)

Hormonal Options

1. For women with an intact uterus:

   • Combined estrogen-progestogen therapy is mandatory to prevent endometrial hyperplasia and cancer 1
   • Recommended regimens:
     • Conjugated equine estrogen 0.625 mg/day with medroxyprogesterone acetate 2.5 mg/day 1
     • Transdermal estradiol 0.05 mg/day patch (applied twice weekly) with oral micronized progesterone 200 mg daily for 12-14 days per month 1

2. For women without a uterus (hysterectomized):

   • Estrogen-only therapy is sufficient 1
   • Options include:
     • Oral conjugated equine estrogen 0.625 mg/day
     • Transdermal estradiol 0.025-0.0375 mg/day patch 1

Non-Hormonal Pharmacologic Options

• Antidepressants: low-dose paroxetine, venlafaxine 2
• Anticonvulsants: gabapentin 2
• Neuronal inhibitors and certain antihypertensives 3

Non-Pharmacological Approaches

• Weight loss if overweight
• Smoking cessation
• Limiting alcohol intake
• Regular physical activity
• Cognitive behavioral therapy 1

Genitourinary Symptoms

Treatment Options

1. Vaginal estrogen (rings, suppositories, creams) for vaginal dryness and atrophy 1
2. Non-hormonal vaginal moisturizers 2
3. Ospemifene - the only FDA-approved non-hormonal treatment for dyspareunia due to menopausal atrophy 2

Risks and Benefits of MHT

Benefits

• Most effective treatment for vasomotor symptoms 4
• Increases bone density and reduces fracture risk 3
• May reduce risk of colorectal cancer 3
• Prevents genitourinary atrophy 1

Risks

• Combined estrogen-progestin therapy increases breast cancer risk when used for more than 3-5 years 2
• Increased risk of venous thromboembolism (relative risk of 3.49 in the first year) 1
• Increased risk of stroke (relative risk of 1.20) 1
• Possible increased risk of coronary heart disease and cholecystitis 1

Special Considerations

Contraindications for MHT

• Active liver disease
• History of breast cancer
• History of coronary heart disease
• Previous venous thromboembolism or stroke 1

Monitoring and Follow-up

• Initial follow-up at 3 months and annual follow-up thereafter
• Monitor blood pressure, weight, lipid profile, symptom control, bleeding patterns
• Annual mammography 1
• Reevaluate need for therapy every 3-6 months 1

Alternative Therapies

The evidence for alternative therapies is limited:

• Clinical hypnosis may significantly reduce hot flashes
• Modest improvement in hot flashes and vaginal dryness with soy products 2
• Limited evidence for yoga, paced respiration, acupuncture, exercise, stress reduction, relaxation therapy, black cohosh, botanical products, omega-3 fatty acid supplements, and dietary Chinese herbs 2

Treatment Algorithm

1. Assess symptom severity and impact on quality of life
2. Evaluate contraindications and risk factors
3. For moderate to severe vasomotor symptoms:
   • If no contraindications: Consider MHT (lowest effective dose, shortest duration)
   • If contraindicated or patient declines MHT: Use non-hormonal pharmacologic options
4. For primarily genitourinary symptoms:
   • Consider local vaginal estrogen or non-hormonal alternatives
5. For all patients: Recommend appropriate lifestyle modifications

Important Caveats

• The USPSTF explicitly recommends against using combined estrogen and progestin or estrogen alone for the prevention of chronic conditions in postmenopausal women (Grade D recommendation) 1
• When discontinuing MHT, gradual reduction of dose by 25-50% every 4-8 weeks is recommended, monitoring for return of vasomotor symptoms 1
• Transdermal estradiol is preferred for women with hypertension 1
• Women with an intact uterus must receive progestogen with estrogen to prevent endometrial hyperplasia and cancer 1