Management of Menopausal Symptoms

Abstract

Most menopausal women experience vasomotor symptoms with bothersome symptoms often lasting longer than one decade. Hormone therapy (HT) represents the most effective treatment for these symptoms with oral and transdermal estrogen formulations having comparable efficacy. Findings from the Women's Health Initiative and other recent randomized clinical trials have helped to clarify the benefits and risks of combination estrogen-progestin and estrogen-alone therapy. Absolute risks observed with HT tended to be small, especially in younger women. Neither regimen increased all-cause mortality rates. Given the lower rates of adverse events on HT among women close to menopause onset and at lower baseline risk of cardiovascular disease, risk stratification and personalized risk assessment appear to represent a sound strategy for optimizing the benefit-risk profile and safety of HT. Systemic HT should not be arbitrarily stopped at age 65 years; instead treatment duration should be individualized based on patients' risk profiles and personal preferences. Genitourinary syndrome of menopause represents a common condition that adversely affects the quality of life of many menopausal women. Without treatment, symptoms worsen over time. Low-dose vaginal estrogen represents highly effective treatment for this condition. Because custom-compounded hormones have not been tested for efficacy or safety, U.S. Food and Drug Administration (FDA)-approved HT is preferred. A low-dose formulation of paroxetine mesylate currently represents the only nonhormonal medication FDA-approved to treat vasomotor symptoms. Gynecologists and other clinicians who remain abreast of data addressing the benefit-risk profile of hormonal and nonhormonal treatments can help menopausal women make sound choices regarding management of menopausal symptoms.

Figure 1

Women’s Health Initiative hormone therapy trials: Absolute risks (cases per 10,000 person-years) for outcomes in the intervention phases of the estrogen-progestin and estrogen-alone trials, by age group. CEE=conjugated equine estrogens; MPA=medroxyprogesterone acetate. Modified from Manson JE, Chlebowski RT, Stefanick ML, Aragaki AK, Rossouw JE, Prentice RL, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA 2013 310:1353–68.

Figure 2

Algorithm for menopausal symptom management developed in collaboration with the North American Menopause Society and available in a free mobile app called MenoPro (dual mode for clinicians and patients). HT=hormone therapy; GSM=genitourinary syndrome of menopause; CVD=cardiovascular disease; SSRI/SNRIs=selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors. Modified from Manson JE, Ames JM, Shapiro M, Gass ML, Shifren JL, Stuenkel et al. Algorithm and mobile app for menopausal symptom management and hormonal/non-hormonal therapy decision making: a clinical decision-support tool from the North American Menopause Society. Menopause 2014;22:247–53