Treatment of menopausal symptoms

Hormone-Replacement Therapy (HRT) for selected women at low risk for cardiovascular disease (CVD) and breast cancer and who are both bothered by their symptoms and are eager to take HRT.

Women are eligible for HRT if they are under the age of 60 and are no more than 10 years into menopause. Physicians also need to assess a patient’s baseline risk for CVD or breast cancer — a high risk for either condition can constitute a contraindication to use of HRT. The evaluation of the risk is performed according to: Standard CVD risk-assessment scores and for cancer, the National Cancer Institute Breast Cancer Risk Assessment Tool by the International Breast Intervention Study calculator.

Vasomotor and Genitourinary Symptoms Warrant Intervention

Menopause symptoms frequently start in the years before the final menstrual period and can last, with unpredictable duration, from a few years to more than 13 years.

The two main symptoms the Endocrine Society’s new guidelines specifically target are vasomotor symptoms (hot flushes/flashes/night sweats) and genitourinary symptoms (vaginal dryness or discharge, pain, burning or itching, urinary frequency, recurrent urinary tract infections).

“The most effective therapy [for both sets of symptoms] is HRT,” Dr Stuenkel said.

It is less clear whether anxiety, irritability, depression, palpitations, skin dryness, loss of libido, and fatigue can be attributed to menopause, the new guidelines state.

Candidates for HRT can receive estrogen replacement alone if they are without a uterus;

if women have a uterus, they require the combination of estrogen plus progestogen to prevent endometrial hyperplasia and cancer.

Additional hormonal options for women with a uterus include estrogen combined with bazedoxifene and tibolone where available.

Other medical options recommended by the Endocrine Society include:

• Transdermal estrogen therapy by patch, gel, or spray for women who want HRT but who have an increased risk of venous thromboembolism.
• Selective serotonin-reuptake inhibitors, serotonin/norepinephrine-reuptake inhibitors, gabapentin, or pregabalin are recommended for women who want medication to manage moderate to severe hot flashes but who prefer either not to take HRT or have significant risk factors that make HRT inadvisable.
• Low-dose vaginal estrogen therapy may be used to treat genitourinary symptom, but even low-dose vaginal estrogen is relatively contraindicated in women with a history of an estrogen-dependent cancer.

Impact of Menopausal Symptoms “Substantial”

“The impact of severe menopausal symptoms on quality of life may be substantial,” Dr Stuenkel noted.

In light of this, there are circumstances under which a woman with a history of coronary artery disease or even breast cancer might choose to accept a degree of risk that initially might outweigh the benefits of HRT.

Stopping HRT an Individual Choice, Too

The guidelines also state that the approach to discontinuation of HRT is an individual choice, too.

Menopausal symptoms and joint pain can recur when HRT is discontinued, and, depending on the severity of the symptoms, women may elect to restart HRT, perhaps at a lower dose, or seek relief with nonhormonal therapies.

“Anecdotally, some women find that a very low dose…maintains adequate symptom relief and well-being and prefer that to complete discontinuation,” state the recommendations.

Resources for patients are available at www.menopausemap.org. The Hormone Health Network also offers a digital toolkit for healthcare providers.