What is the treatment for a 47-year-old perimenopausal patient with irregular menstrual cycles and severe vasomotor symptoms, specifically hot flashes?

From the Guidelines

For a 47-year-old perimenopausal patient with irregular menses and severe hot flushes, the most effective treatment option is hormone therapy, but due to potential health risks, non-hormonal options such as selective serotonin reuptake inhibitors (SSRIs) or gabapentin should be considered first, as recommended by the American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline 1. The patient's symptoms can be managed with non-hormonal options, including:

• Selective serotonin reuptake inhibitors (SSRIs) like paroxetine 7.5-25 mg daily or venlafaxine 37.5-150 mg daily
• Gabapentin 300-900 mg daily
• Lifestyle modifications, such as maintaining a cool environment, wearing layered clothing, avoiding triggers like spicy foods, alcohol, and caffeine, and practicing stress reduction techniques If non-hormonal options are not effective, hormone therapy can be considered, but it should be used with caution and at the lowest effective dose, as recommended by the NCCN clinical practice guidelines in oncology 1. Some key points to consider when prescribing hormone therapy include:
• The progestin component is essential for patients with an intact uterus to provide endometrial protection
• Estrogen transdermal formulations may be preferred over other formulations due to lower rates of venous thromboembolism (VTE) and stroke
• Micronized progestin may be preferred over medroxyprogesterone acetate (MPA) due to lower rates of VTE and breast cancer risk Regular follow-up every 3-6 months is important to assess symptom control and adjust therapy as needed, as recommended by the NCCN clinical practice guidelines in oncology 1. Nonpharmacologic treatments, including acupuncture, exercise/physical activity, yoga, lifestyle modifications, weight loss if overweight or obese, hypnosis, and cognitive behavioral therapy (CBT) may also help manage hot flashes, as recommended by the NCCN clinical practice guidelines in oncology 1.

From the FDA Drug Label

When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. 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. The usual initial dosage range is 1 to 2 mg daily of estradiol adjusted as necessary to control presenting symptoms.

The patient is perimenopausal, not postmenopausal, and has severe hot flushes.

• The lowest effective dose of estradiol should be used, and the patient should be reevaluated periodically (e.g., every 3-6 months) to determine if treatment is still necessary.
• The patient should be started on 1-2 mg daily of estradiol, adjusted as necessary to control symptoms, and the medication should be discontinued as promptly as possible.
• Since the patient has a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer 2.

From the Research

Treatment Options for Perimenopausal Patients

• Hormone therapy (HT) is considered the most effective treatment for managing vasomotor symptoms (VMS), including hot flushes and night sweats, in perimenopausal and postmenopausal women 3, 4.
• Nonhormonal options, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), have been shown to be effective in reducing the frequency and severity of hot flashes in menopausal women 3, 5, 6.
• Specific SSRIs, such as paroxetine, citalopram, and escitalopram, have been found to be effective in reducing hot flashes, while venlafaxine and desvenlafaxine are effective SNRIs 5, 6.
• Gabapentin and clonidine may also be effective, but their use may be limited by poor tolerability and adverse effects 3.

Considerations for Treatment

• The choice of treatment should be based on a careful assessment of the risk-benefit ratio and individual patient preference 3.
• Women with a history of breast cancer and taking tamoxifen should avoid SSRIs, which can interfere with tamoxifen metabolism, and instead consider SNRIs 5.
• Treatment should start with the lowest dose available, and patients should be monitored for side effects, such as nausea and constipation, which are common with SSRIs and SNRIs 5, 6.

Management of Perimenopause

• Perimenopause, or the menopausal transition, can present complex management decisions for providers, and symptoms such as hot flashes, vaginal and sexual changes, altered mood and sleep, and changing bleeding patterns can significantly affect quality of life 7.
• A comprehensive evaluation and evidence-based management approach are necessary to address the unique needs of perimenopausal women 7.