What is the recommended medication regimen for managing menopause symptoms?

Recommended Medication Regimen for Managing Menopause Symptoms

For managing menopausal symptoms, menopausal hormone therapy (MHT) is the most effective treatment, with specific regimens including estrogen alone for women without a uterus and combination estrogen-progestin therapy for women with an intact uterus. 1

Initial Assessment

• Evaluate for medical causes of symptoms (thyroid disease, diabetes)
• Laboratory evaluation as clinically indicated:
  • Estradiol, FSH, LH, prolactin
  • Note: FSH is not reliable in women with prior chemotherapy, pelvic radiation, or on tamoxifen 2
• For vaginal dryness: Perform pelvic evaluation to assess for vaginal atrophy

First-Line Treatment Options

For Women with an Intact Uterus:

• Combination therapy required to prevent endometrial cancer 3
• Preferred regimen:
  • 17β-estradiol (transdermal): 0.025-0.0375 mg/day patch 1
  • Micronized progesterone: 200 mg orally for 12-14 days per month 1

For Women without a Uterus:

• Estrogen-only therapy 2, 3
• Recommended dosage:
  • Estradiol: 1-2 mg daily, adjusted to control symptoms 3
  • Transdermal estradiol preferred for women with hypertension 1

Administration Approach

• Start with lowest effective dose 3
• Use for shortest duration consistent with treatment goals 3
• Cyclic administration (e.g., 3 weeks on, 1 week off) 3
• Reevaluate every 3-6 months to determine if treatment is still necessary 3

Non-Hormonal Alternatives

For women with contraindications to hormonal therapy or who prefer non-hormonal options:

• First-line non-hormonal medications:

  • Venlafaxine/desvenlafaxine: 37.5-75 mg/day
  • Paroxetine: 12.5-25 mg/day
  • Gabapentin: 900 mg/day 1
  • Clonidine (limited efficacy evidence) 1

• Non-pharmacological options:

  • Cognitive behavioral therapy
  • Hypnosis (can decrease daily hot flashes by 59%)
  • Paced respiration training and relaxation techniques 1

Contraindications to Hormone Therapy

Absolute contraindications include:

• History of hormone-related cancers
• Active liver disease
• History of abnormal vaginal bleeding
• Previous venous thromboembolism or stroke
• Coronary heart disease 2, 1

Monitoring and Follow-up

• Initial follow-up at 3 months
• Annual follow-up thereafter
• Assess:
  • Blood pressure
  • Weight
  • Symptom control
  • Bleeding patterns 1
• Consider bone mineral density testing for patients with estrogen deficiency 1

Important Considerations and Pitfalls

1. Risk assessment is crucial: Combined estrogen-progestin therapy increases breast cancer risk, with risk increasing with duration of use 1

2. Transdermal delivery preferred: Transdermal estradiol has better cardiovascular safety profile than oral formulations 1, 4

3. Progestin selection matters: Micronized progesterone appears to have a better safety profile than synthetic progestins 1, 4

4. Duration matters: Use the lowest effective dose for the shortest duration to minimize risks 3

5. Common pitfall: Continuing therapy without periodic reassessment - always reevaluate every 3-6 months 3

6. Race considerations: Black women may experience more hot flashes than white women, independent of HRT status 5

7. Weight considerations: Obese women may experience more hot flashes even on HRT 5