gynecology and obstetrics
Menopause
Treatment of Menopause
Nonpharmacologic measures (eg, cognitive-behavioral therapy, clinical hypnosis) Hormone therapy (estrogens, progestogens, and selective estrogen receptor modulators) Nonhormonal medications (eg, selective serotonin reuptake inhibitors, neurokinin receptor antagonists) (See also theAmerican College of Gynecologists and Obstetricians' Practice Bulletin No. 141.) Treatment of menopause is symptomatic (eg, to relieve hot flushes and symptoms due to vulvovaginal atrophy). Patient education about the physiologic causes of menopause and possible symptoms and signs helps patients manage the changes that occur. In addition to treatment of menopausal symptoms, postmenopausal women should be Diagnosis if they meet the following criteria: Those who have a high risk of fracture (eg, patients with a family history of osteoporosis) Those who have a history of Introduction to Eating Disorders , a low body mass index (BMI), chronic corticosteroid use, All women ≥ 65 years old Nonpharmacologic options shown to be effective in randomized trials for the treatment of vasomotor symptoms ( Treatment references ) include cognitive-behavioral therapy ( For women with obesity, weight loss is effective, particularly during early perimenopause ( Treatment references , Stellate ganglion blockade is also effective for vasomotor symptoms of menopause ( Treatment references ). This procedure is also to treat migraine and complex regional pain syndrome and involves injection of an anesthetic at the lower cervical or upper thoracic region of the anterior cervical spine. Many different types of nonpharmacologic interventions have been suggested to manage menopausal symptoms. The following measures are not recommended by the North American Menopause Society because there are insufficient or negative data about their efficacy in reducing vasomotor symptoms ( Treatment references ): Cooling techniques (eg, lowering the thermostat, using fans, layered or light clothing, cooling sheets or other bedding) Avoiding triggers (eg, spicy food, alcohol,caffeine) Dietary modifications Exercise Yoga Relaxation Paced respiration (taking several slow, deep breaths with inhaling through the nose and exhaling through the mouth) Mindfulness-based interventions Chiropractic interventions Acupuncture Calibration of neural oscillations Many of these interventions have other health benefits and a low potential for harm. For example, a healthy diet is important for health promotion and chronic disease prevention, and exercise, yoga, and relaxation techniques may improve sleep and reduce stress. Individual women may find some of these measures helpful for vasomotor symptoms. However, clinicians should counsel women against using unproven methods that are invasive or have other potential for harm (eg, extreme diets). In addition, the benefits of unproven treatments do not outweigh the burden on patients if measures are expensive, time-consuming, or physically demanding. Over-the-counter vaginal lubricants and moisturizers help relieve vaginal dryness. Sexual intercourse or other vaginal stimulation helps preserve vaginal elasticity in menopausal patients. Menopausal Hormone Therapy with estrogen, a progestogen, or both is the most effective treatment for menopausal symptoms. To prevent endometrial neoplasia in women with a uterus (ie, have not had a hysterectomy), estrogen must be given in combination with a progestogen (to oppose the effect of Ospemifene, a SERM, can be used to treat dyspareunia due to vaginal atrophy if women are not able to self-administer vaginal estrogen therapy or vaginal dehydroepiandrosterone (eg, if they have severe arthritis).Ospemifenemay increase the risk of venous thrombosis. Choice of systemic hormone therapy is given with conjugated may be used with risks of slight increase in hot flashes, leg cramps, or venous thrombosis. No increased risk of stroke was seen but, in women at high risk of cardiac disease, a small increase in fatal stroke was seen ( Treatment references ). The SERMstamoxifenandraloxifenehave been used primarily for their antiestrogenic properties and not to relieve menopausal symptoms. In well-designed, randomized controlled trials, nonhormonal medications that have proven efficacy for management of vasomotor symptoms are as follows (however, all of these medications are less effective than hormone therapy) ( Treatment references ): Neurokinin receptor antagonists Selective serotonin reuptake inhibitors (SSRIs) Serotonin-norepinephrinereuptake inhibitors (SNRIs) Gabapentin Oxybutynin (a selective neurokinin-3 receptor antagonist) ( Treatment references , Forfezolinetant, potential side effects include abdominal pain, diarrhea, difficulty sleeping, back pain, hot flushes, and rare reports of liver injury. Liver function tests are needed before startingfezolinetantand every 3 months for first 9 months of treatment.Fezolinetantis contraindicated in patients using CYP1A2 inhibitors (eg,ciprofloxacin,cimetidine, and other medications). , an anticholinergic that is used to treat overactive bladder, also effectively treats vasomotor symptoms (doses in studies have included 2.5 or 5 mg twice daily; or up to 15 mg extended-release once daily) ( Treatment references ). A wide variety of dietary supplements have been suggested to manage menopausal symptoms. There are no supplements with proven efficacy for vasomotor symptoms, and their use is not recommended by the North American Menopause Society ( Treatment references ). Supplements that have limited or inconsistent evidence of benefit include soy food and soy extracts, soy metabolite equol, pollen extract, ammonium succinate,lactobacillusacidophilus, and rhubarb. Supplements with no demonstrated evidence of benefit includeblack cohosh, evening primrose oil, wild yam, omega-3 fatty acid, and cannabinoids. Some herbal preparations or other supplements interact with other medications. Because not all complementary and alternative medicine therapies are efficacious and safe, clinicians should discuss the risks and benefits of these therapies to make sure that women are well-informed ( Treatment references ). 1.The 2023 nonhormone therapy position statement of The North American Menopause Society.Menopause30(6):573-590, 2023. doi:10.1097/GME.0000000000002200 2.Mann E, Smith MJ, Hellier J, et al: Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial.Lancet Oncol13(3):309-318, 2012. doi:10.1016/S1470-2045(11)70364-3 3.Ayers B, Smith M, Hellier J, Mann E, Hunter MS: Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial.Menopause19(7):749-759, 2012. doi:10.1097/gme.0b013e31823fe835 4.Elkins G, Marcus J, Stearns V, et al: Randomized trial of a hypnosis intervention for treatment of hot flashes among breast cancer survivors.J Clin Oncol26(31):5022-5026, 2008. doi:10.1200/JCO.2008.16.6389 5.Elkins GR, Fisher WI, Johnson AK, et al: Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial.Menopause20(3):291-298, 2013. doi:10.1097/gme.0b013e31826ce3ed 6.Thurston RC, Ewing LJ, Low CA, et al: Behavioral weight loss for the management of menopausal hot flashes: A pilot study.Menopause22 (1):59–65, 2015. doi: 10.1097/GME.0000000000000274 7.Huang AJ, Subak LL, Wing R, et al: An intensive behavioral weight loss intervention and hot flushes in women [published correction appears inArch Intern Med170(17):1601, 2010].Arch Intern Med170(13):1161-1167, 2010. doi:10.1001/archinternmed.2010.162 8.Walega DR, Rubin LH, Banuvar S, et al: Effects of stellate ganglion block on vasomotor symptoms: findings from a randomized controlled clinical trial in postmenopausal women.Menopause21(8):807-814, 2014. doi:10.1097/GME.0000000000000194 9.Liu JH: Selective estrogen receptor modulators (SERMS): keys to understanding their function.Menopause27(10):1171-1176, 2020. doi:10.1097/GME.0000000000001585 10.Johnson KA, Martin N, Nappi RE, et al: Efficacy and safety offezolinetantin moderate-to-severe vasomotor symptoms associated with menopause: a phase 3 RCT [published online ahead of print, 2023 Feb 3].J Clin Endocrinol Metabdgad058, 2023. doi:10.1210/clinem/dgad058 11.Lederman S, Ottery FD, Cano A, et al:Fezolinetantfor treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): a phase 3 randomised controlled study.Lancet401(10382):1091-1102, 2023. doi:10.1016/S0140-6736(23)00085-5 12.Pinkerton JV, Redick DL, Homewood LN, Kaunitz AM: Neurokinin receptor antagonist,fezolinetant, for treatment of menopausal vasomotor symptoms [published online ahead of print, 2023 Apr 25].J Clin Endocrinol Metabdgad209, 2023. doi:10.1210/clinem/dgad209 13.Simon JA, Gaines T, LaGuardia KD; Extended-Release Oxybutynin Therapy for VMS Study Group: Extended-releaseoxybutynintherapy for vasomotor symptoms in women: a randomized clinical trial.Menopause23(11):1214-1221, 2016. doi:10.1097/GME.0000000000000773 14.Loprinzi CL, Diekmann B, Novotny PJ, et al: Newer antidepressants andgabapentinfor hot flashes: a discussion of trial duration.Menopause16(5):883-887, 2009. doi:10.1097/gme.0b013e31819c46c7 15.Johnson A, Roberts L, Elkins G: Complementary and alternative medicine for menopause.J Evid Based Integr Med24:2515690X19829380, 2019. doi: 10.1177/2515690X19829380 