What are the recommended maintenance medications and supplements for managing menopause symptoms?

Maintenance Medications and Supplements for Menopause

For moderate to severe menopausal symptoms, menopausal hormone therapy (MHT) remains the most effective treatment, but non-hormonal pharmacologic options should be tried first in most women due to safety considerations. 1

Initial Assessment

Before initiating treatment, evaluate for alternative medical causes of symptoms:

• Check thyroid function and screen for diabetes before attributing symptoms to menopause 1
• Laboratory testing may include estradiol, FSH, LH, and prolactin as clinically indicated 1
• Note: FSH is unreliable in women with prior chemotherapy, pelvic radiation, or those taking tamoxifen 1
• Perform pelvic examination for women complaining of vaginal dryness to assess for vaginal atrophy 1

First-Line Non-Hormonal Pharmacologic Options

For Vasomotor Symptoms (Hot Flashes/Night Sweats)

Antidepressants are the preferred first-line prescription option:

• Venlafaxine (SNRI): Effective for reducing hot flash frequency and severity 2, 1
• Paroxetine (SSRI): Demonstrated efficacy but avoid in women taking tamoxifen due to CYP2D6 inhibition that reduces tamoxifen effectiveness 1
• Fluoxetine (SSRI): Shown to be effective 3
• Doses are typically lower than those used for depression 1

Anticonvulsants:

• Gabapentin: Effective for reducing hot flash frequency and severity 2, 1, 3
• Pregabalin: Also shown efficacy 1

Antihypertensives:

• Clonidine: May decrease hot flash intensity but has relatively high rate of adverse effects 1, 3

For Vaginal Dryness and Dyspareunia

Non-hormonal vaginal treatments:

• Water-based lubricants and moisturizers are primary first-line treatments 1
• Silicone-based products may last longer than water-based or glycerin-based alternatives 1
• Vaginal dilators or pelvic floor relaxation techniques for dyspareunia 1

Lifestyle Modifications

Weight loss of ≥10% may eliminate hot flash symptoms 1

Smoking cessation improves frequency and severity of hot flashes 1

Limit alcohol intake if it triggers hot flashes in individual patients 1

Cognitive behavioral therapy (CBT) reduces the perceived burden of hot flashes 1

Physical activity is recommended for overall health, though direct evidence for vasomotor symptom improvement is limited 1

Menopausal Hormone Therapy (MHT)

MHT is the most effective treatment for vasomotor symptoms but should be reserved for moderate to severe symptoms unresponsive to non-hormonal options 1, 4, 5, 6, 7, 3

Formulation Selection

For women with an intact uterus:

• Combination estrogen plus progestogen is required to prevent endometrial cancer 2, 1, 4, 7
• Micronized progestin is preferred over medroxyprogesterone acetate (MPA) due to lower rates of VTE and breast cancer risk 2
• Alternative: Estrogen combined with bazedoxifene (a SERM) for women who cannot tolerate progestogens 2, 4, 7

For women without a uterus:

• Estrogen alone is appropriate 2, 1

Route of Administration

Transdermal estrogen formulations are preferred over oral due to lower rates of venous thromboembolism and stroke 2

Available formulations include oral, transdermal patches, vaginal rings, and intrauterine devices 2

Dosing Principles

Use the lowest effective dose for the shortest duration to control symptoms 2, 4

Treatment should be individualized based on patient-specific risks and requires specialist management 2, 1

Absolute Contraindications to MHT

• History of hormone-related cancers (breast, endometrial) 2, 1
• History of abnormal vaginal bleeding 2, 1
• Active or recent thromboembolic event 2
• Pregnancy 2, 1
• Active liver disease 2, 1

Use with Caution

• Coronary heart disease or hypertension 2
• Current smokers 2
• Increased genetic cancer risk 2

Special Populations

Young women with premature menopause:

• Consider oral contraceptives or MHT for symptom relief and potential cardiac and bone benefits if not contraindicated 2, 1

Local Vaginal Estrogen Therapy

For isolated vaginal symptoms:

• Low-dose vaginal estrogen (tablets, rings, creams) are effective for vaginal atrophy and dryness 2, 1
• Results take 6-12 weeks to become apparent 1
• Safety in women with breast cancer history is not well established 1
• Not recommended for women on aromatase inhibitors 1
• Evidence suggests local estrogen does not increase breast cancer recurrence risk 2

Supplements and Alternative Therapies

Vitamin E and D:

• Topical vitamin D or E may help with vaginal dryness 2

Soy products:

• Modest improvement in hot flashes and vaginal dryness suggested by one systematic review 4
• Insufficient evidence for isoflavone supplements from soy or red clover 3

Black cohosh:

• Insufficient clinical trial evidence to support or refute efficacy 3
• No serious side effects with short-term use 3

Not recommended due to lack of efficacy:

• Dong quai, evening primrose oil, ginseng, Chinese herbal mixtures, acupuncture, magnet therapy showed no benefit in clinical trials 3
• Yoga, paced respiration, exercise, stress reduction, relaxation therapy, omega-3 fatty acids, botanical products lack high-quality consistent evidence 4

What NOT to Use

Custom-compounded bioidentical hormones are NOT recommended as data supporting claims of superior safety or effectiveness compared to standard hormones are lacking 2, 1

Tibolone should be avoided as it may increase breast cancer recurrence risk 2

Common Pitfalls

Avoid paroxetine in women taking tamoxifen due to drug interaction that reduces tamoxifen efficacy 1

Do not rely on FSH levels in women with prior chemotherapy, pelvic radiation, or those on tamoxifen for determining menopausal status 1

Refer to appropriate specialists for MHT dosing and management rather than attempting complex hormone management in primary care 2, 1