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

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November 15, 2022

Treatment of Vasomotor Symptoms in Menopause

SUMMARY:

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.

 

RECOMMENDATIONS:

  • 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

     

    RISKS AND BENEFITS:

  • 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.

 

 

REFERENCES:

  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
  3. https://www.aafp.org/patient-care/clinical-recommendations/all/hrt.html.
  4. https://www.aafp.org/pubs/afp/issues/2018/0715/p117.html
  5. https://www.aafp.org/news/health-of-the-public/uspstf-hormone-therapy-final.html