What medications should be given to a postmenopausal woman with hot flashes, elevated Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) levels, and an intact uterus?

Management of Menopausal Symptoms in Women with Intact Uterus

For a postmenopausal woman with hot flashes, elevated FSH and LH levels, and an intact uterus, combined estrogen-progestin hormone therapy is the most effective treatment option, but should be prescribed at the lowest effective dose for the shortest duration needed to control symptoms. 1, 2

First-Line Treatment Options

Combined Estrogen-Progestin Therapy

• For women with an intact uterus, estrogen must always be combined with a progestogen to prevent endometrial cancer 1, 2, 3
• Recommended regimens:
  • Conjugated equine estrogen 0.625 mg/day with medroxyprogesterone acetate 2.5 mg/day, OR
  • Transdermal estradiol 0.025-0.0375 mg/day patch with micronized progesterone 200 mg orally for 12-14 days per month 1
• Transdermal estradiol is preferred over oral formulations due to its improved safety profile 1

Dosing Considerations

• Start at the lowest effective dose (usually 1-2 mg daily of estradiol) 2
• Adjust as necessary to control symptoms 2
• Administration should be cyclic (e.g., 3 weeks on and 1 week off) 2
• Reevaluate every 3-6 months to determine if treatment is still necessary 1, 2

Important Risk Considerations

Combined estrogen-progestin therapy carries several risks that must be weighed against benefits:

• Increases risk of:

  • Breast cancer (with use >3-5 years)
  • Coronary heart disease
  • Stroke
  • Venous thromboembolism
  • Pulmonary emboli 1, 3

• Decreases risk of:

  • Colorectal cancer
  • Hip fractures 1

• Absolute contraindications:

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

Non-Hormonal Alternatives

For women who cannot or choose not to use hormone therapy, effective non-hormonal options include:

1. SSRIs/SNRIs:

   • Venlafaxine, paroxetine, desvenlafaxine 1, 3
   • Low-dose paroxetine is FDA-approved for hot flashes 3

2. Other medications:

   • Gabapentin
   • Clonidine 1, 3

3. Non-pharmacological approaches:

   • Cognitive behavioral therapy
   • Clinical hypnosis (shown to significantly reduce hot flashes) 1, 3
   • Regular weight-bearing exercise
   • Maintaining healthy weight
   • Smoking cessation 1

4. For vaginal symptoms:

   • Vaginal moisturizers and lubricants
   • Low-dose vaginal estrogen if non-hormonal options fail 1

Monitoring and Follow-up

• Initial follow-up at 3 months after starting therapy
• Annual follow-up thereafter
• Monitor:
  • Blood pressure
  • Weight
  • Lipid profile
  • Symptom control
  • Bleeding patterns 1

Clinical Pitfalls to Avoid

1. Never use estrogen alone in women with an intact uterus - this increases risk of endometrial cancer 1, 2, 3

2. Do not discontinue progesterone before estrogen in combined therapy to prevent unopposed estrogen effects on the endometrium 1

3. Avoid bioidentical hormone therapy - lacks FDA approval and has insufficient safety data 1

4. Do not prescribe hormone therapy for women with contraindications such as history of breast cancer, active liver disease, or previous thromboembolism 1

5. Do not continue therapy indefinitely - regularly reassess the need for continued treatment 1, 2