What are the treatment options for managing menopause symptoms?

Treatment of Menopause Symptoms

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms, reducing hot flash frequency by approximately 75%, and should be offered as first-line therapy to symptomatic women under age 60 or within 10 years of menopause onset who lack contraindications. 1

Initial Assessment

Evaluate the following symptom domains to guide treatment selection:

• Vasomotor symptoms (hot flashes, night sweats) - most pronounced in first 4-7 years but can persist over a decade 2
• Genitourinary symptoms (vaginal dryness, dyspareunia, urinary complaints) - tend to be progressive and will not resolve without treatment 3, 4
• Sleep disturbances, mood changes, sexual dysfunction 1
• Impact on quality of life using menopause-specific tools like MENQOL 1

Laboratory testing (estradiol, FSH, LH, prolactin) should be obtained as clinically indicated, though FSH is unreliable in women with prior chemotherapy, pelvic radiation, or tamoxifen use 3. For vaginal complaints, perform pelvic examination to assess for vaginal atrophy 1.

Treatment Algorithm

Step 1: Lifestyle Modifications (All Women)

Implement these foundational interventions regardless of symptom severity:

• Identify and avoid personal triggers through a hot flash diary (spicy foods, caffeine, alcohol, stress) 1
• Environmental modifications: dress in layers, keep rooms cool, use cold packs 3
• Weight loss ≥10% of 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 1

Step 2: Screen for MHT Contraindications

Absolute contraindications to MHT include:

• History of hormone-dependent cancers (breast, endometrial) 1
• Active or history of venous thromboembolism 3
• Active liver disease 3
• Unexplained vaginal bleeding 3
• History of stroke or coronary heart disease 1

Step 3: Choose Treatment Based on Contraindication Status

For Women WITHOUT Contraindications (Age <60 or <10 years from menopause onset):

MHT is first-line therapy:

• Women with intact uterus: Combination estrogen PLUS progestin (estradiol 1-2 mg daily with appropriate progestin) 1, 3
• Women without uterus: Estrogen alone 1, 3
• Use lowest effective dose for shortest duration necessary 1
• Expected benefit: 75% reduction in vasomotor symptom frequency 1

Critical caveat: MHT carries risks including increased stroke, venous thromboembolism, and possibly breast cancer (with estrogen plus progestin) that must be weighed against benefits 1. The benefit:risk ratio is most favorable in women under 60 and within 10 years of menopause onset 5.

Bioidentical hormones: FDA-approved bioidentical hormones are available, but custom-compounded bioidentical hormones have no data supporting claims of increased safety or efficacy 1.

For Women WITH Contraindications or Who Decline MHT:

First-line non-hormonal pharmacologic options:

SSRIs/SNRIs (40-65% reduction in hot flashes):

• Venlafaxine, citalopram, escitalopram, desvenlafaxine 3
• Doses typically lower than those needed for depression 3
• Avoid paroxetine in women taking tamoxifen due to CYP2D6 inhibition 1, 3

Gabapentin:

• Effective for reducing hot flashes 1, 3
• Particularly useful at bedtime due to sedating effects 1, 3

Clonidine:

• Shows some benefit but limited efficacy compared to other options 1, 3

Step 4: Genitourinary Symptom Management

For vaginal dryness and dyspareunia:

First-line: Non-hormonal water-based lubricants and moisturizers 3

If inadequate response: Low-dose vaginal estrogen (rings, suppositories, creams) or ospemifene 3, 5

Important: Unlike vasomotor symptoms, genitourinary symptoms will not resolve without treatment and tend to be progressive 2, 4.

Additional Evidence-Based Adjunctive Therapies

• Cognitive behavioral therapy (CBT): Reduces perceived burden of hot flashes 3
• Clinical hypnosis: 59% decrease in daily hot flashes with significant quality of life improvements 1
• Paced respiration and relaxation techniques (20 min/day): Significant benefits 1
• Acupuncture: Mixed results but may improve sleep quality 1

High-dose vitamin E (800 IU/day) shows limited efficacy and supplemental vitamin E >400 IU/day has been linked with increased all-cause mortality 1.

Special Populations

Women with breast cancer on endocrine therapy:

• Avoid MHT - use non-hormonal options (SSRIs/SNRIs, gabapentin) 1, 3
• If symptoms are severe and refractory, consider modifying or switching endocrine therapy (e.g., between aromatase inhibitor and tamoxifen) if oncologically appropriate 1

Ongoing Management

• Establish realistic expectations: Many women are satisfied with 50% reduction in symptom severity 1
• Attempt intermittent discontinuation (perhaps annually) to assess whether symptoms recur 1
• For women on MHT: Use lowest effective dose for shortest duration, typically preferably ≤5 years 6, 5