Treatment of Vasomotor Symptoms in Menopause | November 2022 | Clinical Corner

November 15, 2022

Treatment of Vasomotor Symptoms in Menopause


Vasomotor and vaginal symptoms are cardinal symptoms of menopause. The occurrence of vasomotor symptoms increases during the transition to menopause and peaks approximately 1 year after the final menstrual period. Systemic estrogen hormone therapy (HT), with or without progestin, is the most effective therapy for menopause-related vasomotor symptoms. Oral and transdermal (i.e., patches, gels, or sprays) estrogen, alone or in combination with progestin, can be used, and have been shown to alleviate vasomotor symptoms.



  • ESTROGEN: All estrogen medications should be given at the lowest effective dosage for the shortest duration necessary to improve symptoms in women without a uterus.
  • COMBINATION: Patients with a uterus who cannot tolerate the adverse effects of progesterone may benefit from Duavee, a combination of 0.45-mg conjugated equine estrogen and the selective estrogen receptor modulator Bazedoxifene, which is approved by the FDA for treating hot flashes.
    • The levonorgestrel-releasing intrauterine system (Mirena) is an off-label option for providing local progestogen to the endometrium for patients who cannot tolerate systemic therapy.
  • SSRI vs SNRI: Low-dose paroxetine (Brisdelle) is the only nonhormonal medication approved by the FDA to treat hot flashes, although other dosages can be used.
    • Venlafaxine is preferred in women with breast cancer because SSRIs may interfere with tamoxifen metabolism.
  • NON-HORMONALS: Other nonhormonal options include gabapentin (Neurontin), clonidine and pregabalin (Lyrica) and should be titrated from a lower dosage.1
  • PRIMARY PREVENTION: American Academy of Family Physicians (AAFP) recommends against using hormone therapy for the primary prevention of chronic or cardiovascular conditions.3, 5



  • Although there are no randomized trials, observational studies have shown that transdermal estrogen, which avoids the first-pass liver effect, may have a lower risk of VTE compared with oral estrogen.2
  • Patients who received estrogen-only therapy have an increased risk of stroke (increased in smokers) and showed a decrease in breast cancers despite an increased risk among all patients.4
  • The risks of combined systemic HT include thromboembolic disease (increased in smokers) and breast cancer.
  • Long-term combination HT decreased the risk of all fractures, but patients had an increased risk of coronary events, venous thromboembolism, breast cancer, gallbladder disease, dementia, and death from lung cancer.4
  • As with other estrogen therapies, Duavee includes a boxed warning of increased risk of dementia in women older than 65 years, endometrial cancer, stroke, and deep venous thrombosis.




  1. Sideras K, Loprinzi CL. Nonhormonal management of hot flashes for women on risk reduction therapy. J Natl Compr Canc Netw. 2010;8(10):1171-1179.
  2. Mohammed K, Abu Dabrh AM, Benkhadra K, et al. Oral vs transdermal estrogen therapy and vascular events: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100(11):4012-4020