What are the recommended hormone therapies and supplements for managing menopause symptoms?

Hormone Therapy and Supplements for Managing Menopausal Symptoms

Hormone replacement therapy (HRT) with 17β-estradiol is the first-line treatment for managing menopausal symptoms and preventing long-term health consequences in women experiencing menopause. 1

Hormone Therapy Options

First-Line Treatment: Estrogen-Based Therapy

• Preferred estrogen component: 17β-estradiol

  • Recommended over ethinylestradiol or conjugated equine estrogens
  • Dosage: 50-100 μg/24 hours via transdermal patches 1
  • Transdermal administration provides better bone protection 1

• For women with intact uterus: Must add progestogen component

  • Preferred: Micronized progesterone (200 mg daily for 12-14 days per month)
  • Alternatives: Dydrogesterone or medroxyprogesterone acetate (2.5 mg/day) 1

• Indications for estradiol therapy 2:

  • Moderate to severe vasomotor symptoms
  • Vulvar and vaginal atrophy
  • Hypoestrogenism due to hypogonadism, castration, or primary ovarian failure
  • Prevention of osteoporosis

Non-Hormonal Options for Vasomotor Symptoms

For women who cannot or prefer not to use hormonal therapies:

• SSRIs/SNRIs: Venlafaxine, desvenlafaxine, paroxetine, citalopram, escitalopram

  • Reduce frequency of vasomotor symptoms by 40-65% 3
  • Mechanism appears independent of antidepressant effect 4
  • Side effects may include headache, nausea, gastrointestinal disturbance, and sexual dysfunction 4

• Other non-hormonal medications:

  • Gabapentin
  • Clonidine (limited efficacy evidence) 4

Treatment for Specific Menopausal Symptoms

For Genitourinary Syndrome of Menopause (GSM)

• Low-dose vaginal estrogen

  • Improves GSM symptom severity by 60-80% 3
  • Minimal systemic absorption 5
  • Consider when topical non-hormonal options fail 1

• Non-hormonal options:

  • Vaginal moisturizers and lubricants for daily comfort and sexual activity 1
  • Ospemifene (for dyspareunia due to menopausal atrophy) 6

For Psychological and Cognitive Symptoms

• Behavioral interventions:
  • Cognitive behavioral therapy 1
  • Hypnosis (shown 59% decrease in daily hot flashes) 4
  • Paced respiration training and relaxation techniques (with proper training) 4

Duration and Monitoring

• Continue HRT at least until average age of natural menopause (around 51 years) 1
• Evaluate treatment effect after 3-6 months 1
• Annual follow-up focusing on:
  • Blood pressure, weight, lipid profile
  • Symptom control and bleeding patterns
  • Compliance 1

Important Contraindications and Risks

HRT is contraindicated in women with:

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

Key risks to consider:

• Increased risk of venous thromboembolism (highest in first year of use)
• Stroke risk
• Breast cancer risk with combined estrogen/progestogen therapy (after 3-5 years of use) 6
• Gallbladder disease 2

Special Considerations

• Breast cancer survivors: HRT generally contraindicated; consider non-hormonal alternatives 4, 1
• Premature ovarian insufficiency: Requires HRT until at least the average age of natural menopause 1
• Complementary measures:
  • Weight-bearing exercise
  • Calcium (1500 mg/day) and vitamin D (400-800 IU/day) supplementation
  • Smoking cessation 1, 2

Practical Approach to Treatment

1. Assess severity of symptoms and contraindications
2. For moderate to severe vasomotor symptoms without contraindications:
   • Start with transdermal 17β-estradiol
   • Add progestogen if uterus is intact
3. For women with contraindications to hormonal therapy:
   • Try SSRIs/SNRIs (venlafaxine, paroxetine) or gabapentin
4. For primarily vaginal symptoms:
   • Consider low-dose vaginal estrogen or non-hormonal moisturizers/lubricants
5. Reassess at 3-6 months and annually thereafter

When discontinuing HRT, gradually reduce dose by 25-50% every 4-8 weeks while monitoring for return of symptoms 1.