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Individualize hormone tx (HT); incorporate tx decision into broader discussion of lifestyle modifications to control sx & assessment of risks of chronic dz (CVD, CVA, VTE, bone loss)1 - Assess CVD, CVA, VTE, estrogen-sensitive CA & bone loss risk before starting HT1,2
- Systemic HT (estrogen +/-progestogen) is most effective tx;3 benefits most likely outweigh risks in pts <60 yo or in those w/in 10y of menopause onset;1 use lowest effective dose for shortest duration needed to alleviate VMS3
- Use progestogen (or combo of CEE w/ bazedoxifene) in all pts w/ uterus using systemic estrogen tx (ET),1 minimum 10-14 days/mo;2 continuous progesterone not recommended;2 micronized progesterone considered safer option when progesterone used4
- Consider transdermal route for ET, may theoretically ↓risk of thromboembolism2
- Lowering HT dose or Δ to transdermal HT may be appropriate as pts age, or in those w/ metabolic syndromes (eg, hypertriglyceridemia w/ risk of pancreatitis or steatohepatosis)1
- Individualize decision to continue HT based on sx & risk/benefit ratio, regardless of pt age;1,3 Beers criteria recommendation to routinely d/c HT @ 65 yo not supported by evidence1
- Reasonable lifestyle solutions: layering of clothing, lower ambient temp, cool drinks (although limited supporting data)3
- If smoker: Advise about risk of thromboembolism & CVD w/ ET, institute aggressive smoking cessation program2
- If nonhormonal options required for tx of VMS (eg, hx of endometrial or breast CA, or pt prefers to avoid HT): SSRIs (only paroxetine is FDA-approved but others work; special considerations apply if hx of breast CA),5 SSNRIs, clonidine, gabapentin,3 pregabalin4
- If hormonal options not used for tx of VMS & GSM sx not relieved w/ OTC tx: low-dose vaginal estrogen tx or other tx (eg, vaginal DHEA or oral ospemifene) recommended1
- In pts w/ hx of endometrial or breast CA: Consider systemic HT only if nonhormonal tx fails & in consultation w/ oncologist1
- Avoid using: compounded bioidentical HT (can consider if allergic to ingredient or if dosage not available in government-approved HT),1 progestin-only HT, testosterone3
- Insufficient evidence for VMS: phytoestrogens,2 herbal supplements (black cohosh,2 St. John’s Wort, ginkgo biloba, ginseng), vitamins;3 avoid many of these in pts w/ hx of hormone-dependent CA,2,4 thromboembolism or CVD2
- Insufficient evidence for GSM: herbal remedies, soy products,3 laser, or radiofrequency tx6
Footnotes 1 NAMS 2022. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022. Jul 1;29(7):767-794. Free full-text PDF
2 AACE 2011. Goodman NF, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Menopause. Endocr Pract. Nov-Dec 2011;17Suppl6:1-25. Accessed 11/30/21
3 ACOG 2014. The American College of Obstetricians and Gynecologists. Management of Menopausal Symptoms. Practice Bulletin Number 141. January 2014. Accessed 11/30/21
4 AACE 2017. Cobin RH, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on Menopause – 2017 Update. Endocr Pract. 2017. Jul;23(7):869-880. Accessed 11/30/21
5 AACE 2017. For breast CA pts on tamoxifen: Avoid paroxetine & fluoxetine (may ↓ efficacy of tamoxifen); use venlafaxine, citalopram, clonidine, gabapentin, or pregabalin for tx of VMS.
For breast CA pts not on tamoxifen: Can consider paroxetine in addition to the above, but insufficient evidence to support use of fluoxetine (should not be used).
For breast CA survivors: Avoid sertraline for tx of VMS.
6 NAMS 2020. The 2020 Genitourinary Syndrome of Menopause Position Statement of The North American Menopause Society. Menopause. 2020. Sep;27(9):976-992. Free full-text PDF
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OTC vaginal lubricants & moisturizers effective in most w/ mild sx,1 but low-dose vaginal estrogen tx (ET) preferred over systemic hormone tx (HT) in those who fail or have more severe sx1-3 - Use vaginal lubricants & moisturizers as 1st-line1 to improve dryness, itching, elasticity & pH balance,2 esp if mild sx1 or in pts wishing to avoid HT2
- Transvaginal ET provides topical effect w/ minimal or lower systemic absorption;1,3,4 although FDA labeling warns of risks assoc w/ systemic HT (CVD, CVA, VTE, endometrial and breast CA), these events are unlikely1
- Progestogen tx not rec’d w/ low-dose vaginal ET, but RCT data lacking beyond 1y;1,3 monitor for vaginal bleeding & eval endometrium if occurs;3 consider TVU surveillance and/or intermittent progestogen in pt w/ endometrial CA risk1
- Other FDA approved tx: vaginal DHEA, ospemifene1,3
- Continue tx as long as bothersome sx persist1
- Pts w/ hx of endometrial or breast CA: Nonhormonal tx is 1st-line,2,3 but low-dose vaginal ET can be considered in consultation w/ oncologist if sx persistent or severe;2,3 ospemifene not rec’d if known/suspected breast CA d/t inadequate study (although prelim data: ↓ incident & recurrent breast CA risk)1
- Insufficient evidence: herbal remedies, soy products,2 laser or radiofrequency tx1
Footnotes 1 NAMS 2020. The 2020 Genitourinary Syndrome of Menopause Position Statement of The North American Menopause Society. Menopause. 2020. Sep;27(9):976-992. Free full-text PDF
2 ACOG 2014. The American College of Obstetricians and Gynecologists. Management of Menopausal Symptoms. Practice Bulletin Number 141. January 2014. Accessed 11/30/21
3 NAMS 2022. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022. Jul 1;29(7):767-794. Free full-text PDF
4 AACE 2017. Cobin RH, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on Menopause – 2017 Update. Endocr Pract. 2017. Jul;23(7):869-880. Accessed 11/30/21
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