Primary Treatment Options for Menopause
Menopausal hormone therapy (MHT) is the most effective treatment for managing vasomotor symptoms of menopause, but should be prescribed at the lowest effective dose for the shortest duration possible due to associated risks.1
Vasomotor Symptoms (Hot Flashes)
Hormonal Options
- Estrogen therapy is the most effective treatment for hot flashes, with combination estrogen and progestin for women with an intact uterus, and estrogen alone for women without a uterus 2, 1
- MHT should be used primarily for symptom management rather than prevention of chronic conditions 1, 2
- Transdermal routes of administration are preferred as they have less impact on coagulation factors 1
Non-Hormonal Pharmacologic Options
- SNRIs (e.g., venlafaxine) can reduce hot flash intensity by 40-65% and are considered safe alternatives 1, 3
- SSRIs can decrease vasomotor symptoms but may interfere with tamoxifen metabolism 1
- Gabapentin has demonstrated effectiveness for hot flash reduction 1, 3
- Low-dose paroxetine is FDA-approved specifically for menopausal hot flashes 3
Non-Pharmacologic Approaches
- Lifestyle modifications including rhythmic breathing, exercise, and avoiding triggers 1
- Environmental modifications such as maintaining cool room temperatures and dressing in layers 1
- Acupuncture has shown some efficacy in reducing menopausal symptoms in meta-analyses 1
Genitourinary Symptoms
- Low-dose vaginal estrogen preparations improve genitourinary symptom severity by 60-80% with minimal systemic absorption 1
- Vaginal moisturizers can reduce symptom severity by up to 50% as non-hormonal alternatives 1
- Silicone-based lubricants may last longer than water-based products for vaginal dryness 1
- Ospemifene is the only FDA-approved non-hormonal treatment for dyspareunia due to menopausal atrophy 3
- Vaginal dilators and pelvic floor relaxation techniques may help with dyspareunia 1
Risk-Benefit Assessment of Hormone Therapy
Benefits
- Reduction in osteoporosis and fractures by approximately 30-50% 1
- Estrogen and progestin therapy decreases the rates of hip, vertebral, and total fractures 2
- Estrogen-only therapy is associated with a small reduction in invasive breast cancer risk 2
Risks
- Combined estrogen/progestin therapy increases the risk of breast cancer when used for more than 3-5 years 3
- Increased risk of stroke, DVT, gallbladder disease, and urinary incontinence with both estrogen-only and combined therapy 2
- Combined therapy shows a trend toward increased risk of cardiac events 2
Contraindications to Hormone Therapy
- History of hormone-dependent cancers 2
- History of abnormal vaginal bleeding 2
- Active liver disease 2
- Recent history of pregnancy 2
- History of thromboembolic events 2
Nutritional and Lifestyle Considerations
- Adequate calcium and vitamin D intake is recommended for all postmenopausal women to reduce bone loss 4, 5
- Regular physical activity and smoking cessation should be encouraged 4
- Balanced nutrition can help manage metabolic changes associated with menopause 5
- Weight-bearing exercise is beneficial for bone health 2
Special Considerations
- For women with a uterus, combined estrogen and progestin therapy is necessary to prevent endometrial cancer 1, 3
- Women who cannot tolerate progestogens may benefit from a combined formulation of estrogen and bazedoxifene 3
- For cancer survivors, non-hormonal approaches are generally preferred, especially with hormone-dependent cancers 2, 1
- The FDA recommends that hormone therapy be prescribed at the lowest effective dose for the shortest duration consistent with treatment goals 2
Treatment Algorithm
First-line for vasomotor symptoms:
First-line for genitourinary symptoms:
Duration of therapy: