What are the treatment options for menopause?

Treatment Options for Menopause

For women with moderate to severe menopausal symptoms, begin with nonhormonal approaches including lifestyle modifications and low-dose SSRIs/SNRIs or gabapentin, reserving menopausal hormone therapy (MHT) as the most effective option for those under 60 years old and within 10 years of menopause onset, using the lowest effective dose for the shortest duration. 1

Initial Assessment

Before initiating treatment, evaluate the following:

• Symptom severity and impact on quality of life using menopause-specific tools, assessing vasomotor symptoms (hot flashes, night sweats), genitourinary symptoms, sleep disturbances, mood changes, and sexual dysfunction 1
• Laboratory evaluation may include estradiol, FSH, LH, and prolactin as clinically indicated, though FSH is unreliable in women with prior chemotherapy, pelvic radiation, or those on tamoxifen 2, 3
• Pelvic examination for women with vaginal dryness complaints to assess for vaginal atrophy 1
• Rule out medical causes such as thyroid disease and diabetes that can mimic menopausal symptoms 2

First-Line Nonhormonal Approaches

Lifestyle Modifications

• Identify and avoid personal triggers through a hot flash diary (common triggers: spicy foods, caffeine, alcohol, stress, hairdryers) 1, 3
• Environmental modifications: dress in layers, wear natural fibers, keep rooms cool, use cold packs 1, 3
• Weight loss of ≥10% body weight may eliminate hot flashes in overweight women 1
• Smoking cessation improves frequency and severity of hot flashes 1
• Regular physical activity for overall health benefits and potential hot flash reduction 1, 3

Nonhormonal Pharmacologic Options

For vasomotor symptoms:

• SSRIs/SNRIs reduce hot flashes by approximately 40-65% and are effective first-line alternatives 1, 4

  • Paroxetine 7.5 mg daily reduces frequency and severity of vasomotor symptoms and nighttime awakenings 2, 3
  • Critical caveat: Avoid paroxetine in women taking tamoxifen due to CYP2D6 inhibition that blocks tamoxifen conversion to active metabolites 2, 1. Evidence is conflicting—one study of 17,000 breast cancer survivors found no increased recurrence, while another study of 2,430 survivors found increased cancer death risk 2
  • Venlafaxine is an effective alternative SNRI 3, 4

• Gabapentin is effective for severe hot flashes and particularly useful at bedtime due to sedating effects 1, 3, 4

• Clonidine shows some benefit but with limited efficacy for mild to moderate symptoms 1, 3

Behavioral and Alternative Approaches

• Clinical hypnosis shows a 59% decrease in daily hot flashes with significant quality of life improvements 1
• Paced respiration and relaxation techniques (20 minutes daily) show significant benefits 1
• Acupuncture has mixed results but may improve sleep quality 1
• High-dose vitamin E (800 IU/day) has limited efficacy, and doses >400 IU/day are linked with increased all-cause mortality 1

Menopausal Hormone Therapy (MHT)

MHT is the most effective treatment for vasomotor symptoms, reducing frequency by approximately 75% 1, 5, 6

Indications and Timing

• Best suited for women under age 60 and within 10 years of menopause onset with moderate to severe symptoms 1, 5, 6
• Initiation many years after menopause is associated with excess coronary risk, whereas initiation soon after menopause is not 6
• Use the lowest effective dose for the shortest duration necessary (preferably ≤4-5 years) 1, 3, 4, 6

Formulations

• Women with intact uterus: combination estrogen plus progestin required to reduce endometrial cancer risk 2, 1, 4
• Women without uterus: estrogen alone 2, 1
• Transdermal estrogen formulations may be preferred over oral due to lower rates of venous thromboembolism and stroke 2
• Micronized progestin may be preferred over medroxyprogesterone acetate due to lower VTE and breast cancer risk 2

Absolute Contraindications

MHT is contraindicated in:

• History of hormone-dependent cancers (breast, endometrial) 2, 1
• History of abnormal vaginal bleeding 2
• Active or recent thromboembolic event 2
• Pregnancy 2
• Active liver disease 2

Risks to Consider

• Increased stroke, venous thromboembolism risk with all MHT 1, 4
• Increased breast cancer risk with estrogen plus progestin when used >3-5 years 4, 6
• Use with caution in women with coronary heart disease, hypertension, current smokers, and those with increased genetic cancer risk 2

Important Note on Bioidentical Hormones

Custom-compounded bioidentical hormones are not recommended as data supporting claims of increased safety or efficacy are lacking 2, 1

Treatment of Vaginal Dryness/Genitourinary Symptoms

• Over-the-counter vaginal moisturizers, gels, oils for comfort 2
• Lubricants for sexual activity 2
• Low-dose vaginal estrogen (rings, suppositories, creams) is highly effective with minimal systemic absorption and does not increase breast cancer recurrence risk 2, 6
• Ospemifene is the only FDA-approved nonhormonal treatment for dyspareunia due to menopausal atrophy 4

Special Populations

Cancer Survivors

• Nonhormonal options preferred as first-line therapy for survivors with menopausal symptoms 2
• MHT can be used in appropriate cancer survivors after trying alternatives first, with referral to specialist for management 2
• For breast cancer patients on endocrine therapy with severe symptoms, consider modifying or switching therapy (e.g., between aromatase inhibitor and tamoxifen) if appropriate 1

Young Women with Early Menopause

• Consider oral contraceptives or MHT for symptom relief and potential cardiac and bone benefits if not contraindicated 2

Treatment Duration and Reassessment

• Attempt to discontinue treatments intermittently (perhaps annually) to assess whether symptoms recur 1
• For women requiring long-term therapy beyond 4-5 years due to severe persistent symptoms, first trial nonhormonal options (gabapentin, SSRIs/SNRIs) before returning to estrogen 6
• Many women may be satisfied with a 50% reduction in symptom severity rather than complete elimination 1