What are the treatment options for menopause?

Treatment for Menopause

For moderate-to-severe vasomotor symptoms in women under age 60 or within 10 years of menopause onset, estrogen-based hormone therapy is the most effective treatment and should be used at the lowest effective dose for the shortest duration necessary. 1, 2

Initial Assessment and Symptom Evaluation

Before initiating treatment, assess the severity and impact of symptoms on quality of life using validated tools such as the MENQOL or FACT-ES questionnaires 3. Common menopausal symptoms include:

• Vasomotor symptoms: hot flashes and night sweats (affecting approximately 75% of women) 4
• Genitourinary symptoms: vaginal dryness, urinary complaints, sexual dysfunction 1
• Other symptoms: sleep disturbance, mood changes, cognitive dysfunction, arthralgias, and fatigue 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 1.

Treatment Algorithm

Step 1: Non-Pharmacological Interventions (All Women)

Implement lifestyle modifications first, as these reduce symptom burden and cardiovascular risk 1, 4:

• Temperature regulation: Dress in layers, wear natural fibers, use cold packs intermittently 1
• Trigger identification: Keep a hot flash diary to identify and avoid triggers such as spicy food, hairdryers, and anxiety 1
• Exercise: Regular physical activity may reduce hot flash frequency and improve quality of life 1
• Weight management: Hot flashes are more severe in overweight women 1
• Smoking cessation: Smokers experience more severe vasomotor symptoms 1
• Calcium and vitamin D: Ensure adequate intake (1500 mg calcium daily, 400-800 IU vitamin D) to reduce bone loss 5, 6

Step 2: Pharmacological Treatment Selection

For Women Under Age 60 or Within 10 Years of Menopause Onset

Hormone Therapy (First-Line for Moderate-to-Severe Symptoms)

• With intact uterus: Estrogen plus progestin to reduce endometrial cancer risk 7, 5

  • Start with estradiol 1-2 mg daily, adjusted to control symptoms 7
  • Or conjugated estrogens 0.3-0.625 mg daily 5
  • Administer cyclically (3 weeks on, 1 week off) 7

• Without uterus: Estrogen alone 7, 5

  • Same dosing as above without progestin 7

• Duration: Use the lowest effective dose for the shortest duration, typically less than 5 years 3, 2, 4

• Reassessment: Attempt to discontinue or taper at 3-6 month intervals 7

Important risks to discuss: Venous thromboembolism, coronary heart disease, and stroke risk increase within the first 1-2 years; breast cancer risk increases with longer-term use 3, 1.

For Women Who Cannot or Will Not Use Hormone Therapy

Non-Hormonal Pharmacological Options (Second-Line)

• SSRIs/SNRIs (most effective non-hormonal option) 1, 4:

  • Paroxetine 7.5 mg daily reduces vasomotor symptom frequency and severity 1
  • Venlafaxine is also effective 1

• Gabapentin: Effective for severe hot flashes 1

• Clonidine: Consider for mild-to-moderate hot flashes 1

Set realistic expectations: Non-hormonal treatments typically achieve approximately 50% reduction in symptom severity, compared to greater efficacy with hormone therapy 3, 4.

Step 3: Genitourinary Symptom Management

For isolated vulvovaginal symptoms without systemic vasomotor symptoms:

• Low-dose vaginal estrogen (preferred): Provides excellent therapeutic response with minimal systemic absorption 6, 2
• Ospemifene: Alternative hormonal option 2
• Non-hormonal options: Vaginal moisturizers and lubricants for those avoiding hormonal therapy 2

Special Considerations

Breast Cancer Survivors

Women with breast cancer history should avoid systemic hormone therapy 3. Treatment options include:

• Non-hormonal pharmacological agents (SSRIs, SNRIs, gabapentin, clonidine) 1
• Lifestyle modifications and trigger avoidance 3
• Low-dose vaginal estrogen may be considered for severe genitourinary symptoms after oncology consultation 3

Osteoporosis Prevention

When prescribing hormone therapy solely for osteoporosis prevention, consider it only for women at significant risk where non-estrogen medications are inappropriate 7, 5. Bone mineral density screening should begin at age 65 for all women, or earlier with additional risk factors 6.

Common Pitfalls to Avoid

• Do not use hormone therapy for primary prevention of coronary heart disease, breast cancer, or dementia—current evidence does not support this 2
• Do not prescribe hormone therapy to women over age 60 or more than 10 years past menopause onset without careful risk-benefit analysis, as cardiovascular risks increase 2
• Do not continue treatment indefinitely: Reassess necessity every 3-6 months and attempt discontinuation annually to determine if symptoms persist 3, 7
• Do not assume all symptoms are menopausal: Mood changes, cognitive dysfunction, and fatigue may be related to depression, anxiety, or other medical conditions requiring separate evaluation 3