What are the treatment options for menopause?

Treatment of Menopause

For symptomatic menopausal women under age 60 or within 10 years of menopause onset, hormone therapy remains the most effective treatment for vasomotor symptoms like hot flashes and night sweats, but should be used at the lowest effective dose for the shortest duration necessary. 1, 2

Initial Assessment

Before initiating any treatment, evaluate the specific symptoms present:

• Vasomotor symptoms (hot flashes, night sweats) are most pronounced in the first 4-7 years but can persist over a decade 3
• Genitourinary symptoms (vaginal dryness, dyspareunia, urinary complaints) tend to be progressive 1, 3
• Other symptoms may include sleep disturbance, mood changes, cognitive dysfunction, sexual dysfunction, and arthralgias 1

Laboratory testing (FSH, LH, estradiol, prolactin) should only be obtained when clinically indicated, as FSH is unreliable in women with prior chemotherapy, pelvic radiation, or those on tamoxifen 1

Treatment Algorithm

First-Line: Non-Pharmacological Interventions

Start all patients with lifestyle modifications regardless of whether pharmacological therapy will be added:

• Dress in layers and wear natural fibers; use cold packs intermittently 1
• Keep a hot flash diary to identify and avoid triggers (spicy foods, hairdryers, anxiety) 1
• Achieve healthy weight and stop smoking, as hot flashes are more severe in overweight women and smokers 1
• Regular exercise may reduce or ameliorate hot flashes in some women 1

Second-Line: Pharmacological Options

For Women Who Can Use Hormone Therapy

Hormone therapy (HT) is the gold standard and FDA-approved treatment for vasomotor symptoms 4, 5, 2

Key prescribing principles:

• Use the lowest effective dose for the shortest possible time 6, 1
• Benefits typically exceed risks for women under age 60 or within 10 years of menopause onset 2
• Women with an intact uterus must receive estrogen combined with progestin or bazedoxifene to minimize endometrial cancer risk 4
• Women who have had a hysterectomy can use estrogen alone 6

Important contraindications and risks:

• Do NOT use HT for primary prevention of chronic diseases (cardiovascular disease, dementia, fractures) - this is a Grade D recommendation 6
• HT increases risk of venous thromboembolism, stroke, coronary heart disease (especially in first 1-2 years), breast cancer (with longer-term use), dementia, gallbladder disease, and urinary incontinence 6, 1
• Screen for cardiovascular and breast cancer risk before initiating 2

For Women Who Cannot or Will Not Use Hormone Therapy

SSRIs/SNRIs are the most effective non-hormonal alternatives:

• Paroxetine 7.5 mg daily reduces frequency and severity of vasomotor symptoms 1
• Venlafaxine is effective for hot flashes 6, 1

Other non-hormonal options:

• Gabapentin for severe hot flashes 6, 1
• Clonidine may be considered for mild to moderate hot flashes 1

Important caveat: Side effects are relatively common with all these non-hormonal agents 6

Genitourinary Syndrome of Menopause

For vaginal dryness and atrophy:

• Low-dose vaginal estrogen is most effective, though safety following breast cancer is not established 6, 2
• Ospemifene (oral SERM) is an alternative 2
• Vaginal moisturizers and lubricants for those not choosing hormonal therapy 2

Special Populations

Women with breast cancer history:

• Avoid systemic hormone therapy 6
• For severe/frequent hot flashes: venlafaxine, paroxetine, or gabapentin have the best supporting data 6
• For vaginal symptoms: topical estrogen is most effective but safety is not established; consider non-hormonal options first 6
• Up to 20% of breast cancer patients consider stopping endocrine therapy due to menopausal symptoms, making symptom management critical for treatment adherence 6

Common Pitfalls to Avoid

• Do not prescribe HT for disease prevention - it should only be used for symptom management 6
• Do not continue HT indefinitely - reassess need regularly and use shortest duration necessary 6, 1
• Do not use unopposed estrogen in women with intact uterus - this increases endometrial cancer risk 6, 4
• Do not assume all menopausal symptoms are vasomotor - assess for the full spectrum including genitourinary, mood, cognitive, and metabolic changes 1, 3