What are the treatment options for managing menopause symptoms?

Treatment Options for Managing Menopause Symptoms

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms, reducing frequency by approximately 75%, and should be used at the lowest effective dose for the shortest duration necessary for women without contraindications. 1, 2

Symptom Assessment and Evaluation

• Menopausal symptoms include hot flashes/night sweats, vaginal dryness, urinary complaints, sexual dysfunction, sleep disturbance, mood changes, 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 1
• FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation exposure, or in those on tamoxifen 1
• For vaginal dryness complaints, a pelvic evaluation should be performed to assess for vaginal atrophy 1

First-Line Non-Hormonal Approaches

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

Non-Hormonal Pharmacologic Options

• SSRIs and SNRIs can reduce hot flashes by approximately 40-65% 1, 2
  • Venlafaxine, paroxetine, citalopram, escitalopram, and desvenlafaxine are effective options 2
  • Caution with paroxetine in women taking tamoxifen due to CYP2D6 inhibition 1, 2
  • Doses for vasomotor symptoms are typically lower than those needed for depression 2
• Gabapentin is effective for reducing hot flashes and may be particularly useful at bedtime due to sedating effects 1, 2
• Clonidine shows some benefit for vasomotor symptoms but with limited efficacy 1, 2

Menopausal Hormone Therapy (MHT)

• MHT is the most effective treatment for vasomotor symptoms, reducing frequency by approximately 75% 1, 2
• For women with an intact uterus, combination estrogen and progestin is required 1, 2
• For women without a uterus, estrogen alone is recommended 1, 2
• MHT carries risks including increased stroke, venous thromboembolism, and possibly breast cancer (with estrogen plus progestin) that must be weighed against benefits 1, 2

Management of Specific Symptoms

For Vasomotor Symptoms (Hot Flashes/Night Sweats)

• First-line for moderate to severe symptoms without contraindications: MHT 1, 2
• Alternative options: SSRIs/SNRIs (e.g., venlafaxine) or gabapentin 1, 2

For Genitourinary Symptoms

• Non-hormonal water-based lubricants and moisturizers as first-line 2
• Vaginal estrogen options include rings, suppositories, and creams for women without contraindications 2

Treatment Algorithm

1. Assess symptom severity and impact on quality of life 2
2. Screen for contraindications to hormonal therapy (history of hormone-related cancers, abnormal vaginal bleeding, active liver disease) 2
3. For women without contraindications to hormonal therapy:
   • Consider MHT (estradiol with appropriate progestin if uterus is intact) 2
   • Use lowest effective dose for shortest duration necessary 1
4. For women with contraindications to hormonal therapy:
   • First-line: SSRIs/SNRIs (e.g., venlafaxine) 2
   • Alternative: Gabapentin (particularly useful at bedtime) 2
5. For genitourinary symptoms:
   • Non-hormonal vaginal moisturizers and lubricants 2
   • Vaginal estrogen for women without contraindications 2

Important Considerations and Caveats

• Women with a history of hormone-dependent cancers should avoid MHT and use non-hormonal options 1
• Bioidentical hormones approved by the FDA are available, but custom-compounded bioidentical hormones have no data supporting claims of increased safety or efficacy 1, 2
• Most women experience menopausal symptoms during the transition or postmenopause, with vasomotor symptoms most pronounced during the first four to seven years but potentially persisting for more than a decade 3
• Genitourinary symptoms tend to be progressive and may require ongoing management 3
• Consider trying to discontinue treatments for hot flashes on an intermittent basis (perhaps annually) to assess whether symptoms recur 1