Menopause and hormone therapy

The Menopause Society2022

Systemic hormone therapy is the most effective treatment for bothersome vasomotor symptoms and for the genitourinary syndrome of menopause, and it prevents bone loss and fracture. A woman with a uterus needs a progestogen alongside systemic estrogen to prevent endometrial hyperplasia and cancer.

The Menopause Society2022

Timing drives the benefit-risk balance. For women under 60 or within 10 years of menopause onset with no contraindications, the balance favors treating bothersome vasomotor symptoms and preventing bone loss. Starting more than 10 years out, or after age 60, makes the balance appear less favorable because the absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia are higher.

The Menopause Society2022

Route can be individualized. Transdermal estrogen bypasses first-pass hepatic metabolism, and observational data suggest less venous thromboembolism risk than oral, though randomized comparisons are lacking; micronized progesterone may be less thrombogenic than other progestogens. For genitourinary symptoms alone, low-dose vaginal estrogen is effective with minimal systemic absorption and generally needs no progestogen. Contraindications include unexplained vaginal bleeding, active liver disease, prior estrogen-sensitive cancer including breast cancer, and prior coronary heart disease (including myocardial infarction), stroke, or venous thromboembolism, or high inherited thrombotic risk.

USPSTF2022Grade D

Do not use hormone therapy to prevent chronic conditions: the USPSTF recommends against combined estrogen and progestin for primary prevention in postmenopausal persons, and against estrogen alone for primary prevention after hysterectomy (both Grade D). This does not apply to treating menopausal symptoms such as hot flashes or vaginal dryness, or to premature (primary ovarian insufficiency) or surgical menopause.

The Menopause Society2022Grade Level III

Individualize duration and reassess periodically. Hormone therapy does not need to be routinely stopped at 60 or 65; for otherwise healthy women with persistent vasomotor symptoms, continuing beyond 65 is reasonable with counseling, regular review of risks and benefits, and shared decision-making. Combined estrogen-progestogen therapy raises breast cancer risk, and observational data show the risk rises with duration of use.

The Menopause Society2023Grade Level I (most options)

Nonhormone options for hot flashes when hormone therapy is unsuitable or declined: recommended are cognitive behavioral therapy, clinical hypnosis, SSRIs or SNRIs (paroxetine 7.5 mg is FDA-approved), gabapentin, and fezolinetant (Level I), oxybutynin, and weight loss or stellate ganglion block. Not recommended: paced respiration, herbal supplements, soy, cannabinoids, acupuncture, exercise or yoga for hot flashes, clonidine, and pregabalin.