What are the management options for menopausal symptoms?

Management of Menopausal Symptoms

The management of menopausal symptoms should prioritize non-hormonal approaches first, with menopausal hormone therapy (MHT) reserved for women without contraindications who have moderate to severe symptoms impacting quality of life. 1, 2

Assessment of Menopausal Symptoms

• Evaluate the frequency and severity of symptoms, including vasomotor symptoms (hot flashes, night sweats), genitourinary symptoms (vaginal dryness, dyspareunia), sleep disturbances, mood changes, and sexual dysfunction 3
• Laboratory evaluation may include estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin as clinically indicated 3
• Note that FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation exposure, or in those on tamoxifen 3
• For vaginal dryness complaints, perform a pelvic evaluation to assess for vaginal atrophy 3
• Establish patient goals and expectations from treatment, as many women may be satisfied with a 50% reduction in symptom severity 3

First-Line Non-Hormonal Approaches

Lifestyle Modifications

• Identify and avoid personal triggers through a hot flash diary (common triggers include spicy foods, caffeine, alcohol, stress) 3
• Environmental modifications such as dressing in layers, keeping rooms cool, and using cold packs 3, 1
• Weight loss of ≥10% of body weight may help eliminate hot flash symptoms in overweight women 1, 2
• Smoking cessation can improve the frequency and severity of hot flashes 1, 2
• Regular physical activity for overall health benefits and potential reduction in hot flashes 3, 1

Non-Hormonal Pharmacologic Options

• SSRIs and SNRIs (venlafaxine, paroxetine, citalopram, escitalopram, desvenlafaxine) reduce hot flashes by approximately 40-65% 3, 1
• Caution with paroxetine in women taking tamoxifen due to CYP2D6 inhibition 3
• Gabapentin is effective for reducing hot flashes and may be particularly useful at bedtime due to sedating effects 3, 1
• Clonidine shows some benefit for vasomotor symptoms but with limited efficacy 1, 2
• For vaginal dryness and dyspareunia, non-hormonal water-based lubricants and moisturizers are first-line treatments 1, 2

Complementary Approaches

• Cognitive behavioral therapy (CBT) can reduce the perceived burden of hot flashes 1, 2
• Acupuncture has demonstrated some efficacy in reducing menopausal symptoms in certain studies 1, 2

Menopausal Hormone Therapy (MHT)

• MHT is the most effective treatment for vasomotor symptoms, reducing frequency by approximately 75% 1, 2, 4
• For women with an intact uterus: combination estrogen and progestin is required 3, 5
• For women without a uterus: estrogen alone is recommended 3, 5
• Use the lowest effective dose for the shortest duration necessary 5
• Typical starting dose is estradiol 1-2 mg daily adjusted as necessary to control symptoms 5
• Patients should be reevaluated periodically (every 3-6 months) to determine if treatment is still necessary 5

Treatment Algorithm Based on Symptom Severity and Risk Factors

For Mild Symptoms:

• Start with lifestyle modifications and environmental adjustments 3
• If insufficient, consider non-hormonal pharmacologic options 3, 1

For Moderate to Severe Symptoms:

• Without contraindications to MHT: Consider MHT (estradiol 1-2 mg daily with appropriate progestin if uterus is intact) 1, 5
• With contraindications to MHT: Use SSRIs/SNRIs or gabapentin 3, 1

For Genitourinary Symptoms:

• First-line: Non-hormonal vaginal moisturizers and lubricants 1, 2
• Second-line (if no contraindications): Vaginal estrogen options (rings, suppositories, creams) 3, 1

Important Considerations and Caveats

• MHT carries risks including increased stroke, venous thromboembolism, and possibly breast cancer (with estrogen plus progestin) that must be weighed against benefits 1, 5
• Women with a history of hormone-dependent cancers should avoid MHT and use non-hormonal options 3, 1
• Bioidentical hormones approved by the FDA are available, but custom-compounded bioidentical hormones have no data supporting claims of increased safety or efficacy 3, 2
• Discontinue treatments for hot flashes on an intermittent (annual) basis to assess whether symptoms recur, as vasomotor symptoms tend to decrease over time 3
• For breast cancer survivors, non-hormonal options are strongly preferred 3, 1
• Pure SSRIs, particularly paroxetine, should be used with caution in women taking tamoxifen due to potential interference with its metabolism 3