Treatment of Symptoms of the Menopause

Publication Date: November 1, 2015
Last Updated: July 25, 2023

Diagnosis

Diagnosis and Symptoms of Menopause

The Endocrine Society (ES) suggests diagnosing menopause based on the clinical menstrual cycle criteria. (2-L)
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If establishing a diagnosis of menopause is necessary for patient management in women having undergone a hysterectomy without bilateral oophorectomy or presenting with a menstrual history that is inadequate to ascertain menopausal status, ES suggests making a presumptive diagnosis of menopause based on the presence of vasomotor symptoms (VMS) and, when indicated, laboratory testing that includes replicate measures of follicle-stimulating hormone (FSH) and serum estradiol. ( 2-L )
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Health Considerations for All Menopausal Women

When women present during the menopausal transition, ES suggests using this opportunity to address bone health, smoking cessation, alcohol use, cardiovascular risk assessment and management, and cancer screening and prevention. ( UGPS )
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Treatment

Hormone Therapy for Menopausal Symptom Relief

Estrogen and Progestogen Therapy

For menopausal women <60 years of age or <10 years past menopause with bothersome vasomotor symptoms (VMS) (with or without additional climacteric symptoms) who do not have contraindications or excess cardiovascular or breast cancer risks and are willing to take menopausal hormone therapy (MHT), ES suggests initiating estrogen therapy (ET) for those without a uterus and estrogen plus progestogen therapy (EPT) for those with a uterus. (2-L)
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Cardiovascular Risk

For women <10 years past menopause onset considering MHT for menopausal symptom relief, ES suggests evaluating the baseline risk of cardiovascular disease (CVD) and taking this risk into consideration when advising for or against MHT and when selecting type, dose, and route of administration. ( 2-L )
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For women at high risk of CVD, ES suggests initiating nonhormonal therapies to alleviate bothersome VMS (with or without climacteric symptoms) over MHT. (2-L)
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For women with moderate risk of CVD, ES suggests transdermal estradiol as first-line treatment, alone for women without a uterus or combined with micronized progesterone (or another progestogen that does not adversely modify metabolic parameters) for women with a uterus, because these preparations have less untoward effect on blood pressure, triglycerides, and carbohydrate metabolism. (2-L)
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Venous Thromboembolic Events

For women at increased risk of venous thromboembolism (VTE) who request MHT, ES recommends a nonoral route of ET at the lowest effective dose, if not contraindicated. (1-L)
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For women with a uterus, ES recommends a progestogen (for example, progesterone and dydrogestone) that is neutral on coagulation parameters. (1-M)
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Breast Cancer

For women considering MHT for menopausal symptom relief, ES suggests evaluating the baseline risk of breast cancer and taking this risk into consideration when advising for or against MHT and when selecting type, dose, and route of administration. ( 2-L )
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For women at high or intermediate risk of breast cancer considering MHT for menopausal symptom relief, ES suggests nonhormonal therapies over MHT to alleviate bothersome VMS. (2-L)
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Tailoring MHT

ES suggests a shared decision-making approach to decide about the choice of formulation, starting dose, the route of administration of MHT, and how to tailor MHT to each woman’s individual situation, risks, and treatment goals. ( UGPS )
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Custom-Compounded Hormones

ES recommends using MHT preparations approved by the US Food and Drug Administration (FDA) and comparable regulating bodies outside the United States and recommend against the use of custom-compounded hormones. (UGPS)
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Conjugated Equine Estrogens with Bazedoxifene

For symptomatic postmenopausal women with a uterus and without contraindications, ES suggests the combination of conjugated equine estrogens (E)/bazedoxifene (BZA) (where available) as an option for relief of VMS and prevention of bone loss. (2-M)
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Tibolone

For women with bothersome VMS and climacteric symptoms and without contraindications, ES suggests tibolone (in countries where available) as an alternative to MHT. (2-L)
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ES recommends against adding tibolone to other forms of MHT. (1-L)
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ES recommends against using tibolone in women with a history of breast cancer. (1-L)
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Clinical Management of Patients Taking Hormone Therapies

Monitoring During Therapy

For women with persistent unscheduled bleeding while taking MHT, ES recommends evaluation to rule out pelvic pathology, most importantly endometrial hyperplasia and cancer. (1-M)
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ES recommends informing women about the possible increased risk of breast cancer during and after discontinuing EPT and emphasizing the importance of adhering to age-appropriate breast cancer screening. ( 1-M )
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ES suggests that the decision to continue MHT be revisited at least annually, targeting the shortest total duration of MHT consistent with the treatment goals and evolving risk assessment of the individual woman. (UGPS)
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For young women with primary ovarian insufficiency (POI), premature or early menopause, without contraindications, ES suggests taking MHT until the time of anticipated natural menopause, when the advisability of continuing MHTcan be reassessed. (2-L)
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Stopping Considerations

For women preparing to discontinue MHT, ES suggests a shared decision-making approach to elicit individual preference about adopting a gradual taper vs. abrupt discontinuation. ( 2-L )
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Nonhormonal Therapies for VMS

For postmenopausal women with mild or less bothersome hot flashes, ES suggests a series of steps that do not involve medication, such as turning down the thermostat, dressing in layers, avoiding alcohol and spicy foods, and reducing obesity and stress. ( 2-L )
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Nonhormonal Prescription Therapies for VMS

For women seeking pharmacological management for moderate to severe VMS for whom MHT is contraindicated, or who choose not to take MHT, ES recommends selective serotonin reuptake inhibitors (SSRIs)/serotonin norepinephrine reuptake inhibitors (SNRIs) or gabapentin or pregabalin (if there are no contraindications) (1-M)
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For those women seeking relief of moderate to severe VMS who are not responding to or tolerating the nonhormonal prescription therapies, SSRIs/SNRIs or gabapentin or pregabalin, ES suggests a trial of clonidine (if there are no contraindications). (2-L)
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Over-the-Counter and Alternative Nonhormonal Therapies for VMS

For women seeking relief of VMS with over-the-counter (OTC) or complementary medicine therapies, ES suggests counseling regarding the lack of consistent evidence for benefit from botanicals, black cohosh, omega-3-fatty acids, red clover, vitamin E, and mind/body alternatives including anxiety control, acupuncture, paced breathing, and hypnosis. ( 2-L )
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Treatment of Genitourinary Syndrome of Menopause

Vaginal Moisturizers and Lubricants

For postmenopausal women with symptoms of vulvovaginal atrophy (VVA), ES suggests a trial of vaginal moisturizers to be used at least twice weekly. (2-L)
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For women who do not produce sufficient vaginal secretions for comfortable sexual activity, ES suggests vaginal lubricants. (2-L)
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Vaginal Estrogen Therapies

For women without a history of hormone- (estrogen) dependent cancers who are seeking relief from symptoms of genitourinary syndrome of menopause (GSM) (including VVA) that persist despite using vaginal lubricants and moisturizers, ES recommends low-dose vaginal ET. (1-M)
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In women who present with symptomatic GSM (including VVA) with a history of breast or endometrial cancer that does not respond to nonhormonal therapies, ES suggests a shared decision-making approach that includes the treating oncologist to discuss using low-dose vaginal ET. ( UGPS )
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For women taking raloxifene, without a history of hormone- (estrogen) dependent cancers, who develop symptoms of GSM (including VVA) that do not respond to nonhormonal therapies, ES suggests adding low-dose vaginal ET. (2-L)
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For women using low-dose vaginal ET, ES suggests against adding a progestogen (ie, no need for adding progestogen to prevent endometrial hyperplasia). (2-VL)
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For women using vaginal ET who report postmenopausal bleeding or spotting, ES recommends prompt evaluation for endometrial pathology. ( 1-L )
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Ospemifene

For treatment of moderate to severe dyspareunia associated with vaginal atrophy in postmenopausal women without contraindications, we suggest a trial of ospemifene. (2-M)
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For women with a history of breast cancer presenting with dyspareunia, we recommend against ospemifene. (1-VL)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Treatment of Symptoms of the Menopause

Authoring Organization

Endocrine Society

Publication Month/Year

November 1, 2015

Last Updated Month/Year

November 5, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The objective of this document is to generate a practice guideline for the management and treatment of symptoms of the menopause.

Target Patient Population

Women diagnosed with menopause

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D008593 - Menopause, D019584 - Hot Flashes

Keywords

menopause, hot flashes

Source Citation

Cynthia A. Stuenkel, Susan R. Davis, Anne Gompel, Mary Ann Lumsden, M. Hassan Murad, JoAnn V. Pinkerton, Richard J. Santen, Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 11, 1 November 2015, Pages 3975–4011, https://doi.org/10.1210/jc.2015-2236