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Medical Management of Menopausal Symptoms

Author: Kathryn I. Marko, MD, NCMP, FACOG

Mentor: Nancy D. Gaba, MD, FACOG
Editor: Jonathan Schaffir, MD

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Menopausal symptoms vary for each woman. Symptoms can arise in the perimenopausal period and last throughout the rest of a woman’s lifetime.

Vasomotor symptoms occur in 75% of women undergoing menopause. The most effective treatment is systemic hormone therapy. Estrogen can be given orally, transvaginally or transdermally. If a woman has a uterus, a progestin or bazedoxifene (a selective estrogen receptor modulator) must be added for endometrial protection. There are benefits to hormone therapy beyond symptom reduction, including reduced risk of fractures, colon cancer, and type 2 diabetes mellitus. Women who initiate hormone therapy between the ages of 50 and 59 years and who are less than 10 years from menopause onset may have a reduced risk of cardiovascular disease. However, hormone therapy should not be used for primary prevention.

Risks of hormone therapy include venous thromboembolism and breast cancer. Venous thromboembolism risk (18 additional cases per 10,000 women-years) can be reduced by administering transdermal estrogen. Breast cancer risk (1 additional case per 1000 women) is increased with combined hormone therapy (estrogen-progestogen) but not with estrogen therapy alone. In most symptomatic women aged 50 to 59 years, the overall benefits of hormone therapy outweigh the risks.

Hormone therapy should be individualized. Women should receive the appropriate dosage for the appropriate time to achieve their treatment goals. Hormone therapy should not be automatically stopped at age 65 years. The decision of whether to discontinue hormone therapy should consider the benefits and risks as women age. Hormone therapy can be stopped without a need for tapering. Unregulated bioidentical hormone therapy should be avoided, as dosing is uncertain and risk profiles remain unestablished.  

Nonhormonal medical therapies for vasomotor symptoms include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, and clonidine. SSRIs and SNRIs are most effective, and paroxetine is the only FDA-approved nonhormonal therapy. Paroxetine may affect the metabolism of tamoxifen and should not be used in women taking this medication. Lifestyle modifications, phytoestrogens, and herbal remedies lack proven efficacy.  

Genitourinary symptoms of menopause (GSM) due to vaginal atrophy occur in 10-40% of women and include vaginal dryness and dyspareunia. All systemic hormone therapies are effective in treating GSM. However, local therapy is preferred if there are no systemic symptoms. Low-dosage estrogen therapy, in cream, tablet, or ring preparations, has minimal systemic absorption and a progestin is not required for endometrial protection. Prasterone, synthetic dehydroepiandrosterone, is a daily vaginal suppository to treat dyspareunia and it elevates serum estrone levels. Ospemifene, an oral selective estrogen receptor modulator, improves symptoms with no endometrial activity. Nonhormonal therapies for GSM include moisturizers and lubricants. Vaginal laser therapies do not have long-term safety or efficacy data to support their use for this indication.

Further Reading:

ACOG Practice Bulletin No. 141: management of menopausal symptoms. Obstet Gynecol. 2014 Jan;123(1):202-16. doi: 10.1097/01.AOG.0000441353.20693.78. Erratum in: Obstet Gynecol. 2016 Jan;127(1):166. Erratum in: Obstet Gynecol. 2018 Mar;131(3):604. PMID: 24463691.

The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017 Jul;24(7):728-753. doi: 10.1097/GME.0000000000000921. PMID: 28650869.

Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov;22(11):1155-72; quiz 1173-4. doi: 10.1097/GME.0000000000000546. PMID: 26382310.

Initial Publication: November 2020, Revised May 2022


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