What are the treatment options for menopause?

Treatment Options for Menopause

For women experiencing menopausal symptoms, hormone therapy is the most effective treatment option for vasomotor symptoms, but non-hormonal alternatives should be considered first-line for most women due to potential risks associated with hormone therapy. 1

Assessment of Menopausal Symptoms

• Menopausal symptoms can include hot flashes/night sweats, vaginal dryness, urinary complaints, sexual dysfunction, sleep disturbance, mood disturbance, depression, cognitive dysfunction, arthralgias/myalgias, and fatigue 2
• Laboratory evaluation may include estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin, as clinically indicated 2
• FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation exposure, or those on tamoxifen 2

Non-Pharmacological Treatments

Lifestyle Modifications

• Dress in layers to easily remove clothes during hot flashes 2
• Wear natural fibers and use cold packs intermittently 2
• Identify and avoid potential triggers (e.g., spicy food, hairdryers, anxiety) by keeping a hot flash diary 2
• Exercise may reduce the risk or ameliorate hot flashes in some women 2
• Achieve a healthy weight and stop smoking, as hot flashes may be more severe in overweight women and smokers 2

Complementary and Alternative Therapies

• Evidence for herbal remedies is inconsistent and inconclusive 2, 3
• High-dose vitamin E (800 IU/day) has shown limited efficacy for mild vasomotor symptoms 2
• Soy products may provide modest improvement in hot flashes and vaginal dryness 4
• Clinical hypnosis has shown significant reduction in hot flashes in small studies 4
• Acupuncture shows mixed results, with some studies suggesting it is superior to placebo but less effective than estrogen for hot flashes 2

Pharmacological Treatments

Non-Hormonal Medications

For Vasomotor Symptoms

• Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are effective alternatives for women who cannot or will not use hormone therapy 2

  • Paroxetine (7.5 mg daily) has been shown to reduce frequency and severity of vasomotor symptoms 2
  • Venlafaxine is also effective for hot flashes 2
  • Caution: SSRIs, particularly paroxetine, should be used with caution in women taking tamoxifen due to potential drug interactions 2

• Gabapentin is effective for severe hot flashes 2

• Clonidine may be considered for mild to moderate hot flashes 2

For Genitourinary Symptoms

• Non-hormonal vaginal moisturizers for vaginal dryness 4
• Ospemifene (the only FDA-approved non-hormonal treatment for dyspareunia due to menopausal atrophy) 4

Hormone Therapy

Menopausal Hormone Therapy (MHT)

• Most effective treatment for vasomotor symptoms 1

• General recommendations:

  • Combination estrogen and progestin for women with an intact uterus 2
  • Estrogen alone for women without a uterus 2
  • Use the lowest effective dose for the shortest possible time 2

• Benefits:

  • Effective relief of hot flashes 2
  • Reduces risk of fractures 2
  • May improve quality of life 5

• Risks:

  • Combined estrogen/progestogen therapy increases risk of breast cancer when used for more than 3-5 years 4
  • Increased risk of venous thromboembolism, coronary heart disease, and stroke within the first 1-2 years of therapy 2
  • Estrogen-only therapy is associated with increased risk of stroke, deep vein thrombosis, and gallbladder disease 2

• Contraindications:

  • History of hormone-related cancers 2
  • History of abnormal vaginal bleeding 2
  • Recent history of pregnancy 2
  • Active liver disease 2

Local Estrogen Treatments

• Vaginal rings, suppositories, or creams for genitourinary symptoms 2
• Lower systemic absorption compared to oral hormone therapy 4

Selective Estrogen Receptor Modulators (SERMs)

• Raloxifene acts as an estrogen agonist in bone, decreasing bone resorption and turnover, increasing bone mineral density, and decreasing fracture incidence 6
• Combined formulation of estrogen and bazedoxifene (a SERM) may benefit women who cannot tolerate adverse effects of progestogens 4

Treatment Algorithm

For Vasomotor Symptoms:

1. Mild symptoms:

   • Start with lifestyle modifications 2
   • Consider vitamin E or clonidine 2

2. Moderate to severe symptoms:

   • First-line (non-hormonal): SSRIs/SNRIs or gabapentin 2
   • Second-line (if non-hormonal treatments fail): Consider hormone therapy if no contraindications exist 2, 1
     • For women with intact uterus: Estrogen plus progestin 2
     • For women without uterus: Estrogen alone 2

For Genitourinary Symptoms:

1. First-line: Non-hormonal vaginal moisturizers and lubricants 4
2. Second-line: Low-dose vaginal estrogen or ospemifene 4

Important Considerations and Caveats

• Benefits of hormone therapy may exceed risks for symptomatic women under age 60 or within 10 years of menopause onset 1
• Hormone therapy should not be used for prevention of chronic diseases such as coronary heart disease, breast cancer, or dementia 2, 1
• Women who decide to take hormone therapy for menopausal symptoms should use the lowest effective dose for the shortest possible time 2
• There is no high-quality evidence supporting the claim that custom-compounded bioidentical hormones are safer or more effective than standard hormone therapies 2
• The decision to use hormone therapy should be based on a thorough evaluation of the risks and benefits for each individual woman 4