Menopause: Key Therapies

Endocrinology, General Med-Peds, Med-Peds Forum / By

What is menopause anyway?

Menopause is cessation of menstrual bleeding for 1 year in the absence of pregnancy, breastfeeding, or underlying pathology. 

  • Average age: 51.4 years +/- 3 years
  • Early onset menopause can be caused by smoking, surgery (e.g.,  hysterectomy), genetics, or malnutrition

Premature ovarian failure (aka primary ovarian insufficiency) is menopause occurring before 40yo. 

Symptoms & Diagnosis

Symptom duration is variable and can last up to 10 years!

  • Hot flashes
  • Mood swings
  • Vaginal dryness, vulvovaginal atrophy, dyspareunia
  • Poor sleep

Menopause is a clinical diagnosis. 

  • Clinical pearls: If diagnosis is questionable, considering checking an FSH level; an FSH level >30 IU/mL is typically consistent with menopause

Treatment

Nonpharmacological therapy:

  • Layered clothing
  • Lower room temperature
  • Use fans
  • Avoid dietary triggers

Pharmacological therapy: 

  • Paroxetine – FDA-approved for moderate-to-severe vasomotor symptoms related to menopause (i.e., hot flushes/flashes, night sweats)
    • Provides relief in days (not weeks!) 
    • Be mindful of potential drug-drug interactions (e.g., tamoxifen)
  • Gabapentin – for night sweats
  • Some alternative therapies have inconsistent evidence
    • ex: soy, isoflavones, black cohosh, weight loss, exercise
  • Other alternative therapies appear to be ineffective
    • ex: acupuncture, evening primrose, flaxseed

Placebo effect occurs in up to 50% of patients on any therapy for menopause!!

Vulvovaginal atrophy: 

  • First line: Daily use of water-based lubricant
  • Second line: Vaginal estrogen cream or ring

What’s the deal with hormonal replacement therapy (HRT)?

HRT is well-known to be effective for vasomotor symptoms and prevention of osteoporosis, but it’s not without risk. 

In 2002, the Women’s Health Initiative, a long-term national health study that focuses on strategies for preventing heart disease, breast and colorectal cancer, and osteoporosis in postmenopausal women, found that post-menopausal women taking combination hormone therapy (estrogen and progestin) for menopausal symptoms had an increased risk of breast cancer, heart disease, stroke, blood clots, and urinary incontinence.

Nevertheless, the WHI found a positive effect of HRT in women <60yo who were <10 years out from menopause. Specifically, they had 30% lower mortality rate and decreased risk of heart disease. 

  • Of note, the above Cochrane Review and USPSTF meta-analyses did not address the use of HRT for menopausal symptoms, nor did they present the WHI data showing the low absolute risks of HRT in younger menopausal women

What to consider when starting HRT: 

  • Age of patient and time since menopause
  • Patient’s risk factors or contraindications [e.g., estrogen-sensitive malignancies (breast, ovarian, endometrial), CAD, prior hx of VTE]
  • Insurance issues – may not be covered or co-pay may be high
  • Start at lowest dose, titrating up as needed, continue for the shortest period of time needed to control symptoms
    • Combination therapy with progesterone is necessary if patient has uterus present to avoid endometrial hyperplasia and potential uterine cancer
  • Follow up within 3 months to assess clinical response
    • No need to evaluate hormone levels

Take-home points!

  • Listen to your patient. If they are having the typical symptoms of perimenopause/menopause, then that’s likely your answer. Menopause is a clinical diagnosis.
  • Try non-pharmacologic treatments first, then move on to pharmacologic therapy, starting with lowest risk (e.g., paroxetine) before moving to highest risk (i.e., HRT)
  • Remember the placebo effect is REAL! 

Blog post based on Med-Peds Forum talk by Kenzie Daniels, PGY4