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 Treatments

• For women with a 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 moderate to severe vulvar and vaginal atrophy
  • Prevention of postmenopausal osteoporosis

Administration Routes

• Systemic options: Oral tablets, transdermal patches, gels, or sprays
• Local options: Vaginal creams, rings, or tablets for genitourinary symptoms 1
• Benefit of transdermal route: May limit venous thromboembolic risk associated with oral estrogens 3

Non-Hormonal Treatment Options

For Vasomotor Symptoms

• Prescription medications:
  • Low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives for hot flashes 4
  • Consider these options for women with contraindications to hormone therapy

For Genitourinary Symptoms

• Vaginal treatments:
  • Non-hormonal vaginal moisturizers and lubricants as first-line treatment 3
  • Vaginal estrogen (creams, rings, tablets) for vaginal dryness and dyspareunia 1
  • Ospemifene - the only FDA-approved non-hormonal treatment for dyspareunia due to menopausal atrophy 4

Complementary Approaches

• Vitamin E: Modest effect on hot flashes at 800 IU/day 1
• Soy products: May provide modest improvement in hot flashes and vaginal dryness 4
• Clinical hypnosis: Small studies suggest significant reduction in hot flashes 4

Lifestyle Modifications

• Physical activity: Regular exercise is recommended for all menopausal women 1
• Bone health: Adequate calcium (1500 mg/day) and vitamin D (400-800 IU/day) intake 2
• Symptom management: Maintaining healthy weight, avoiding triggers, and dressing in layers 1

Risk Considerations and Contraindications

Risks of Hormone Therapy

• Combined estrogen/progestogen therapy increases breast cancer risk when used for more than 3-5 years 4
• Cardiovascular risks, including venous thromboembolism and stroke, may increase within the first 1-2 years of therapy 1

Absolute Contraindications

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

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:
   • First-line: MHT if no contraindications exist and within 10 years of menopause or under age 60 5
   • Alternative: Non-hormonal options if MHT is contraindicated
4. For genitourinary symptoms:
   • First-line: Vaginal moisturizers and lubricants
   • Second-line: Low-dose vaginal estrogen or ospemifene 3
5. For osteoporosis prevention:
   • Consider MHT in early postmenopausal women at low to moderate fracture risk 3
   • Ensure adequate calcium and vitamin D intake 2

Common Pitfalls to Avoid

• Prolonged use without reassessment: Regularly reevaluate the benefit-risk balance of MHT
• One-size-fits-all approach: Treatment should be tailored based on symptom profile and risk factors
• Overlooking non-hormonal options: Many effective alternatives exist for women who cannot or prefer not to use hormonal therapy
• Ignoring timing: Benefits of MHT generally outweigh risks when started within 10 years of menopause onset 6

Remember that menopausal symptoms remain substantially undertreated 6, yet appropriate management can significantly improve quality of life during this transition.