What is the first line management for menopause and menopausal symptoms?

First-Line Management for Menopause and Menopausal Symptoms

For women without contraindications to hormone therapy who are under age 60 or within 10 years of menopause onset, menopausal hormone therapy (MHT) is the most effective first-line treatment for vasomotor symptoms, reducing hot flashes by approximately 75% compared to placebo. 1, 2, 3 However, for women with contraindications or those preferring non-hormonal options, gabapentin 900 mg/day or venlafaxine 37.5-75 mg/day should be used as first-line therapy. 1

Treatment Algorithm Based on Patient Profile

For Women WITHOUT Contraindications to Hormones

Start with MHT if the patient meets all of the following criteria:

• Age <60 years OR within 10 years of menopause onset 2, 3
• No history of hormone-related cancers (breast, endometrial) 4
• No history of abnormal vaginal bleeding 4
• No active or recent thromboembolic events 5
• No active liver disease 4
• Moderate to severe vasomotor symptoms affecting quality of life 3

MHT dosing specifics:

• Women with intact uterus: Combination estrogen PLUS progestin (to protect endometrium from malignancy) 4, 6
• Women post-hysterectomy: Estrogen alone 4
• Start at lowest effective dose, typically estradiol 1-2 mg daily 5
• Use transdermal formulations preferentially due to lower rates of venous thromboembolism and stroke compared to oral 1
• Reassess every 3-6 months to determine if treatment is still necessary 5

For Women WITH Contraindications or Preferring Non-Hormonal Treatment

First-line non-hormonal pharmacologic options (choose based on clinical scenario):

Gabapentin 900 mg/day at bedtime is preferred when: 1

• Patient has concurrent sleep disturbance from hot flashes 1
• Patient is on multiple medications (gabapentin has no known drug interactions) 1
• Patient is taking tamoxifen (avoids CYP2D6 interaction) 1
• Reduces hot flash severity by 46% vs 15% with placebo 1, 7
• Side effects affect up to 20% but improve after first week 1

Venlafaxine 37.5 mg daily, increasing to 75 mg after 1 week is preferred when: 1, 7

• Rapid onset is prioritized (faster action than gabapentin) 7
• Patient prefers it based on tolerability profile 1
• Gabapentin is ineffective or not tolerated 1
• Reduces hot flash scores by 37-61% 1
• 68% of patients prefer venlafaxine over gabapentin despite similar efficacy 1

Paroxetine 7.5-20 mg daily:

• Reduces hot flash frequency, severity, and nighttime awakenings by 62-65% 1
• CRITICAL WARNING: Avoid in women taking tamoxifen due to CYP2D6 inhibition that reduces tamoxifen efficacy 1, 7

Alternative pharmacologic options:

• Clonidine can reduce hot flash frequency and severity but has more side effects and slower onset than venlafaxine 1, 7
• Review efficacy at 2-4 weeks for SSRIs/SNRIs and 4-6 weeks for gabapentin; switch to another agent if intolerant or ineffective 1

Non-Pharmacologic Approaches (Adjunctive to Pharmacologic Treatment)

Evidence-based non-pharmacologic interventions:

• Weight loss ≥10% of body weight may eliminate hot flash symptoms 1, 7
• Smoking cessation improves frequency and severity of hot flashes 1, 7
• Acupuncture shows equivalence or superiority to venlafaxine or gabapentin in some studies 1, 7
• Cognitive behavioral therapy (CBT) reduces perceived burden of hot flashes 1, 7
• Paced respiration training (structured breathing exercises for 20 minutes daily) shows significant benefit 1
• Hypnosis showed 59% decrease in daily hot flashes with significant quality of life improvement 1
• Yoga may improve quality of life but effects on hot flash frequency are inconsistent 1

Management of Genitourinary Symptoms

For vaginal dryness, dyspareunia, and urinary symptoms:

First-line non-hormonal:

• Water-based or silicone-based vaginal lubricants and moisturizers 7
• Silicone-based products last longer than water-based or glycerin-based 7
• Vaginal dilators or pelvic floor relaxation techniques for dyspareunia 7

If non-hormonal options fail:

• Low-dose vaginal estrogen (rings, suppositories, creams) for women without hormone-dependent cancers 4
• Results take 6-12 weeks to become apparent 7
• Contraindicated in women on aromatase inhibitors 7
• Safety not well established in women with history of breast cancer 7

Critical Contraindications and Safety Warnings

Absolute contraindications to MHT: 4, 5

• History of hormone-related cancers (breast, endometrial, low-grade serous ovarian, granulosa cell tumors) 4
• Abnormal vaginal bleeding (must evaluate for malignancy first) 4, 5
• Active or recent thromboembolic events 5
• Active liver disease 4
• Pregnancy 4

Important drug interaction:

• Never use paroxetine or fluoxetine in women taking tamoxifen due to CYP2D6 inhibition; use venlafaxine, citalopram, or gabapentin instead 1

MHT risks to discuss with patients:

• Combined estrogen/progestogen increases breast cancer risk when used >3-5 years 1
• Increases risk of stroke and venous thromboembolism 1
• U.S. Preventive Services Task Force recommends AGAINST using MHT for chronic disease prevention (Grade D recommendation) 4

Common Pitfalls to Avoid

• Do not use custom-compounded bioidentical hormones - no data supports claims of superior safety or efficacy compared to standard hormone therapies 4, 7
• Do not delay treatment - menopausal symptoms remain substantially undertreated despite effective options that significantly improve quality of life 7, 8
• Do not ignore the robust placebo response (up to 70% in some studies) when evaluating treatment efficacy 1
• Do not use vitamin E >400 IU/day - doses above this are linked to increased all-cause mortality 1
• Do not use MHT to prevent coronary heart disease, breast cancer, or dementia - current evidence does not support this 2