Usual Menopausal Medication in Canada
For menopausal symptom management in Canada, hormone therapy (HT) using the lowest effective dose for the shortest possible time is recommended, with transdermal estradiol being preferred over oral formulations due to its superior safety profile.
First-Line Treatments for Menopausal Symptoms
Hormone Therapy Options
Estrogen-based therapy:
For women with intact uterus (requires progestogen to prevent endometrial hyperplasia):
- Medroxyprogesterone acetate (2.5 mg/day) or
- Micronized progesterone (200 mg orally for 12-14 days per month) 1
Treatment Algorithm
Vasomotor symptoms (hot flashes, night sweats):
- Start with lowest effective dose of HT
- Transdermal estradiol preferred over oral formulations due to lower risk of venous thromboembolism 1
- Evaluate effectiveness after 3-6 months
Genitourinary symptoms (vaginal dryness, dyspareunia):
- Low-dose vaginal estrogen if systemic HT not needed/contraindicated
- Vaginal moisturizers and lubricants for daily comfort and sexual activity 1
Non-Hormonal Alternatives
For women with contraindications to HT or who prefer non-hormonal options:
Medications:
Non-pharmacological approaches:
- Cognitive behavioral therapy
- Paced respiration and meditation
- Regular weight-bearing exercise
- Maintaining healthy weight
- Smoking cessation 1
Important Considerations and Cautions
Contraindications for Hormone Therapy
- History of hormone-related cancers
- Active liver disease
- History of abnormal vaginal bleeding
- Previous venous thromboembolism or stroke
- Coronary heart disease 3, 1
Risk Assessment
HT carries risks that must be weighed against benefits:
- Combined estrogen-progestin therapy increases risk of coronary heart disease, stroke, pulmonary emboli, and invasive breast cancer 3
- Benefits include decreased risk of colorectal cancer and hip fractures 3
- Risk increases with duration of use, particularly for breast cancer 3
Special Populations
- Cancer survivors: Generally avoid systemic HT; non-hormonal options preferred 3
- Women with premature menopause: May have more favorable benefit-risk ratio for HT 1
Monitoring and Follow-up
- Initial follow-up at 3 months after starting therapy
- Annual follow-up thereafter
- Assessment should include blood pressure, weight, symptom control, and bleeding patterns 1
Canadian Context
Canada has fewer HT product options compared to other developed countries, with only 28 brands and 22 active ingredients available 4. This limited selection may impact treatment choices for Canadian women experiencing menopausal symptoms.
Discontinuation
When discontinuing HT, gradual reduction of dose by 25-50% every 4-8 weeks is recommended, with monitoring for return of vasomotor symptoms 1.
The decision to use HT should be made after careful consideration of the individual woman's symptoms, medical history, and personal preferences, with the goal of using the lowest effective dose for the shortest duration necessary to manage symptoms.