What are the treatment recommendations for menopause?

From the Guidelines

Hormone replacement therapy (HRT) is not recommended for the primary prevention of chronic conditions in postmenopausal women, but it can be considered for the management of menopausal symptoms. For women with an intact uterus, a combination of estrogen (such as estradiol 0.5-1mg daily or estradiol patch 0.025-0.1mg/day) plus progesterone (such as micronized progesterone 100-200mg daily or medroxyprogesterone acetate 2.5-5mg daily) is recommended to prevent endometrial hyperplasia 1. Women who have had a hysterectomy can take estrogen alone. For those who cannot or prefer not to use hormonal treatments, non-hormonal options include selective serotonin reuptake inhibitors (SSRIs) like paroxetine 7.5-25mg daily or venlafaxine 37.5-150mg daily for hot flashes 1. Gabapentin 300-900mg daily or clonidine 0.1-0.2mg daily can also help with vasomotor symptoms. Vaginal dryness can be treated with local estrogen preparations (creams, rings, or tablets) or moisturizers. Lifestyle modifications including regular exercise, maintaining healthy weight, avoiding triggers like alcohol and spicy foods, and practicing stress reduction techniques can complement medical treatments.

Some key points to consider:

• The USPSTF recommends against the use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women 1.
• The use of HRT for relieving active symptoms of menopause is outside the scope of the USPSTF recommendations, but it can be considered for women with severe symptoms 1.
• Non-hormonal options like SSRIs and gabapentin can be effective for managing vasomotor symptoms 1.
• Lifestyle modifications can complement medical treatments and improve overall health and well-being.

It's essential to individualize decision-making and consider the specific patient's situation, preferences, and values when making treatment decisions. Clinicians should understand the evidence and discuss the potential benefits and harms of HRT with their patients.

From the FDA Drug Label

The Women’s Health Initiative (WHI) enrolled approximately 27,000 predominantly healthy postmenopausal women in two substudies to assess the risks and benefits of daily oral conjugated estrogens (CE) [0.625 mg]-alone or in combination with medroxyprogesterone acetate (MPA) [2. 5 mg] compared to placebo in the prevention of certain chronic diseases.

The treatment recommendations for menopause are not directly stated in the provided drug labels. However, the labels mention the use of conjugated estrogens and progesterone in the treatment of postmenopausal women, suggesting that hormone replacement therapy (HRT) may be a treatment option for menopause symptoms.

• The WHI study 2 compared the effects of conjugated estrogens alone and conjugated estrogens plus medroxyprogesterone acetate on the risk of certain chronic diseases in postmenopausal women.
• The study found that the combination of conjugated estrogens and medroxyprogesterone acetate increased the risk of breast cancer, stroke, and pulmonary embolism, while reducing the risk of colorectal cancer and hip fracture. However, the labels do not provide specific treatment recommendations for menopause, and the decision to use HRT should be made on a case-by-case basis, taking into account the individual woman's medical history, risk factors, and symptoms.

From the Research

Treatment Options for Menopause

• Hormone replacement therapy (HRT) with estrogen, progesterone, or a combination is effective in reducing menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause 3, 4
• Non-hormonal medications, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), can be used to treat vasomotor symptoms, including hot flashes and night sweats 5, 3, 6
• Gabapentin is also a non-hormonal medication that can be used to treat vasomotor symptoms 5, 3
• Lifestyle modifications, including diet and exercise, may help alleviate menopausal symptoms, although the evidence is limited 5, 7
• Cognitive behavior therapy and clinical hypnosis may be effective in reducing vasomotor symptoms and associated sleep disturbances 3
• Hormone-free vaginal moisturizers and ospemifene can be used to treat genitourinary syndrome of menopause, including vaginal dryness and dyspareunia 3

Non-Pharmacological Interventions

• Nutrition counseling and intervention can help reduce the risk of diseases associated with menopause, such as cardiovascular disease and osteoporosis 7
• A balanced diet that includes key preventive nutrients, such as vitamin D, calcium, and protein, can help alleviate menopausal symptoms 7
• Sleep and relaxation techniques, such as mindfulness and meditation, may help reduce stress and alleviate menopausal symptoms 7

Pharmacological Interventions

• SSRIs, such as escitalopram, paroxetine, and fluoxetine, have been shown to be effective in reducing the frequency and severity of hot flashes 6
• SNRIs, such as venlafaxine and desvenlafaxine, have also been shown to be effective in reducing the frequency and severity of hot flashes 6
• Gabapentin has been shown to be effective in reducing the frequency and severity of hot flashes, although the evidence is limited 5, 3