What are the treatment options for a woman experiencing menopausal symptoms?

Treatment of Menopausal Symptoms

For women experiencing bothersome menopausal symptoms without contraindications, menopausal hormone therapy (MHT) with estrogen (plus progestin if uterus intact) is the most effective first-line treatment, reducing vasomotor symptoms by approximately 75%. 1, 2

Treatment Algorithm by Symptom Type and Patient Characteristics

For Vasomotor Symptoms (Hot Flashes, Night Sweats)

First-Line for Women Without Contraindications:

• Initiate systemic estrogen therapy (oral or transdermal) combined with progestin if the uterus is intact, or estrogen alone if the uterus has been removed. 1, 3, 4 Oral and transdermal formulations have similar efficacy. 2
• Use the lowest effective dose for the shortest duration necessary, typically not exceeding 4-5 years, as breast cancer risk increases with longer duration. 5, 6
• MHT is most appropriate for women under age 60 or within 10 years of menopause onset, when the benefit-to-risk ratio is most favorable. 5, 7

First-Line for Women With Contraindications or Who Prefer Non-Hormonal Options:

• SNRIs (venlafaxine, desvenlafaxine) or SSRIs (paroxetine, citalopram, escitalopram) reduce vasomotor symptoms by approximately 40-65%. 1, 2 These are the preferred non-hormonal pharmacologic options. 1, 3
• Gabapentin is effective for reducing hot flashes (40-65% reduction) and particularly useful at bedtime due to sedating effects. 1, 3, 2
• Clonidine shows limited efficacy but may be considered as a third-line option. 1, 3

For Genitourinary Symptoms (Vaginal Dryness, Dyspareunia)

First-Line Non-Hormonal:

• Non-hormonal water-based vaginal lubricants and moisturizers are the initial treatment for genitourinary symptoms. 1, 3

Second-Line Hormonal (if non-hormonal options inadequate):

• Low-dose vaginal estrogen (rings, suppositories, creams) provides 60-80% improvement in symptom severity with minimal systemic absorption. 6, 2 This is preferred over systemic therapy when treating isolated genitourinary symptoms. 5
• Vaginal prasterone improves symptoms by 40-80%, and oral ospemifene by 30-50%. 2

Non-Pharmacologic Interventions (Should Be Recommended for All Patients)

Lifestyle Modifications:

• Weight loss of ≥10% body weight may eliminate hot flashes in overweight women. 1, 3
• Smoking cessation improves frequency and severity of hot flashes. 1, 3
• Limit alcohol intake if it triggers hot flashes. 1, 3
• Identify personal triggers (spicy foods, caffeine, stress) through a hot flash diary. 1, 3

Environmental and Behavioral Strategies:

• Dress in layers, keep rooms cool, use cold packs. 1, 3
• Cognitive behavioral therapy (CBT) reduces the perceived burden of hot flashes. 1, 3
• Acupuncture has demonstrated efficacy in some studies. 1, 3
• Yoga may improve quality of life associated with menopause. 1, 3

Absolute Contraindications to Hormonal Therapy

Do not prescribe MHT in women with:

• History of hormone-dependent cancers (breast, endometrial). 5, 3
• History of abnormal vaginal bleeding (unexplained). 5, 3
• Active or recent thromboembolic disorders. 3
• Active liver disease. 5, 3

Risks of Menopausal Hormone Therapy

Quantified Risks (Important for Informed Consent):

• Stroke, venous thromboembolism, and breast cancer (with estrogen plus progestin) each increase by approximately 1 excess event per 1,000 person-years. 2
• Risks for venous thromboembolism, coronary heart disease, and stroke are highest within the first 1-2 years of therapy. 5
• Breast cancer risk appears to increase with longer-term use (beyond 4-5 years). 5, 6
• Low-dose conjugated equine estrogen plus bazedoxifene is not associated with increased breast cancer risk. 2

Special Populations

Women With History of Breast Cancer:

• Non-hormonal options (SNRIs, SSRIs, gabapentin) are strongly preferred. 1, 3
• MHT is contraindicated. 5, 3

Young Women With Premature Menopause:

• Oral contraceptives may provide symptom relief in young cancer survivors experiencing early menopause. 5, 3

Common Pitfalls to Avoid

• Do not use MHT for prevention of cardiovascular disease, dementia, or breast cancer—current evidence does not support these indications. 2, 7
• Do not rely on FSH levels to confirm menopausal status in women with prior chemotherapy, pelvic radiation, or those on tamoxifen, as FSH is unreliable in these contexts. 3
• Avoid custom-compounded bioidentical hormones—there is no data supporting claims that they are safer or more effective than FDA-approved hormone therapies. 5
• When prescribing solely for prevention of osteoporosis, consider non-estrogen medications first. 4