From the Guidelines
Menopause is best managed with hormone replacement therapy (HRT) for symptom relief, using the lowest effective dose for the shortest possible time, as recommended by the USPSTF 1. The goal of treatment is to alleviate symptoms while minimizing risks. Key considerations include:
- HRT options: estrogen alone (for women without a uterus) or estrogen plus progestin (for women with a uterus)
- Standard HRT options: oral estradiol (0.5-1mg daily), transdermal patches (0.025-0.1mg/day), or vaginal estrogen for localized symptoms
- Non-hormonal options: SSRIs/SNRIs like paroxetine (7.5mg daily) or venlafaxine (75mg daily), gabapentin (300mg at bedtime), or clonidine (0.1mg daily)
- Lifestyle modifications: regular exercise, maintaining healthy weight, avoiding triggers (caffeine, alcohol, spicy foods), dressing in layers, and practicing relaxation techniques These approaches work by either replacing declining hormones or targeting the brain's temperature regulation and neurotransmitter systems affected by estrogen withdrawal. Regular healthcare visits during this transition are important to monitor symptoms and overall health, as the USPSTF recommends against the routine use of estrogen and progestin for the prevention of chronic conditions in postmenopausal women 1. The benefits and harms of HRT vary for different hormone regimens, and until data indicate that other HRT regimens have a favorable balance of benefits to harms, a cautious approach would be to avoid using HRT routinely for the specific purpose of preventing chronic disease in women 1. The USPSTF found fair to good evidence that the combination of estrogen and progestin has both benefits and harms, including increased bone mineral density, reduced risk for fracture, and reduced risk for colorectal cancer, as well as increased risk for breast cancer, venous thromboembolism, coronary heart disease, stroke, and cholecystitis 1. Ultimately, decisions to initiate or continue HRT for menopausal symptoms should be made on the basis of discussions between a woman and her clinician, taking into account individual risk factors and preferences 1.
From the FDA Drug Label
For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. Estradiol is used to: reduce moderate to severe hot flashes Estrogens are hormones made by a woman's ovarats Between ages 45 and 55, the ovarats normally stop making estrogens. This leads to a drop in body estrogen levels which causes the “change of life” or menopause
Menopause Treatment: Estradiol is used to reduce moderate to severe hot flashes and other symptoms associated with menopause. The lowest effective dose should be used for the shortest duration consistent with treatment goals.
- Key points:
- Estradiol is used to treat moderate to severe vasomotor symptoms and vulval and vaginal atrophy associated with menopause.
- The lowest dose and regimen that will control symptoms should be chosen.
- Medication should be discontinued as promptly as possible.
- Treatment should be reevaluated periodically (e.g., 3-month to 6-month intervals) to determine if it is still necessary 2 2.
From the Research
Definition and Symptoms of Menopause
- Menopause is a natural stage that occurs when women stop menstruating, typically between the ages of 45 years and 56 years 3.
- During the menopausal transition, approximately 50% to 75% of women have hot flashes, night sweats, or both (vasomotor symptoms) and more than 50% have genitourinary symptoms (genitourinary syndrome of menopause [GSM]) 3.
- Vasomotor symptoms typically last more than 7 years and GSM is often chronic 3.
Treatment Options for Menopausal Symptoms
- Efficacious treatments for women with bothersome vasomotor symptoms or GSM symptoms include hormonal and nonhormonal options 3.
- Systemic estrogen alone or combined with a progestogen reduces the frequency of vasomotor symptoms by approximately 75% 3.
- Nonhormonal approaches such as citalopram, desvenlafaxine, escitalopram, gabapentin, paroxetine, and venlafaxine are available and are associated with a reduction in frequency of vasomotor symptoms by approximately 40% to 65% 3.
- Low-dose vaginal estrogen is associated with subjective improvement in GSM symptom severity by approximately 60% to 80% 3.
Role of Diet in Managing Menopausal Symptoms
- Dietary modifications and food supplements may be explored by some women as alternatives to hormone replacement therapy 4.
- Soy isoflavones may reduce the frequency and/or severity of vasomotor symptoms, although results are inconsistent 4.
- Adopting a healthier dietary pattern may support a healthy bodyweight and benefit vasomotor symptoms 4.
Hormone Replacement Therapy (HRT)
- HRT is the first-line therapy for bothersome vasomotor symptoms and GSM symptoms, but nonhormonal medications also can be effective 3, 5.
- The benefits of HRT in improving the symptoms of menopause are well-established, but potential risks associated with HRT must also be considered 5, 6.
- Women younger than 60 years or who initiate HRT within 10 years of menopause onset may gain short-term benefit in terms of symptomatic relief and long-term benefit in terms of protection from chronic diseases 6.
Bioidentical Menopausal Hormone Therapy
- Registered bioidentical sex hormones have several advantages over conventional menopausal hormone therapy, including a lower risk of venous thromboembolic and ischemic stroke events 7.
- Transdermal estradiol may be superior to conjugated equine estrogens in terms of global cardiovascular health 7.
- Combining oral micronized progesterone with transdermal estradiol can be considered as the optimal menopausal hormone therapy, with a better breast profile and lower risk of breast cancer 7.