Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline Original paper

What was studied?

This guideline reviews the treatment of menopausal symptoms, focusing on vasomotor symptoms (VMS) such as hot flashes and night sweats, as well as the genitourinary syndrome of menopause (GSM). The paper provides recommendations on managing these symptoms through menopausal hormone therapy (MHT) and non-hormonal treatments. It emphasizes the importance of individualizing therapy based on patient-specific risks and preferences, including the choice between oral, transdermal, and vaginal estrogen routes. The guideline also discusses the safety and efficacy of various therapies, including estrogen-progestogen combinations, and addresses issues like cardiovascular risk, venous thromboembolism, and breast cancer risk.

Who was studied?

The guideline focuses on postmenopausal women, specifically those who are experiencing troublesome vasomotor symptoms, genitourinary issues, and other climacteric symptoms. It addresses women under 60 years or within 10 years of menopause who are generally healthy but may have specific risks, such as cardiovascular concerns or breast cancer history. The document also includes considerations for women with a uterus who need progestogen therapy alongside estrogen and those with a history of breast cancer who need alternative, non-hormonal treatments. The focus is on personalizing treatment based on the severity of symptoms, health status, and patient preference.

Most important findings

The guideline emphasizes that menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms, particularly when initiated early (before age 60 or within 10 years of menopause). Estrogen therapy (ET) significantly reduces hot flashes and night sweats, while estrogen-progestogen therapy (EPT) is recommended for women with a uterus to protect the endometrium. The guideline favors transdermal estrogen over oral forms for women with cardiovascular risks due to lower thrombotic risks. Non-hormonal therapies, such as SSRIs, SNRIs, gabapentin, and clonidine, are recommended for women who cannot use hormones or prefer alternatives. Vaginal estrogen, including low-dose preparations, is recommended for genitourinary symptoms like vaginal dryness and dyspareunia, with benefits that likely extend to vaginal microbiome health, though microbial data is not provided in the guideline. The use of vaginal moisturizers and lubricants is also suggested for symptom relief in women not opting for hormone therapy. The paper underscores the need for regular screening for breast cancer and cardiovascular risks before initiating MHT and stresses that shared decision-making is crucial to managing menopausal symptoms effectively.

Key implications

Clinicians should initiate MHT for vasomotor symptom relief in women under 60 or within 10 years of menopause, taking into account individual risk factors like cardiovascular health and breast cancer risk. Transdermal estradiol should be prioritized for women with higher cardiovascular risks. For women with an intact uterus, a progestogen must be used to protect the endometrium. Non-hormonal alternatives should be considered for those who prefer not to use hormones or have contraindications. Clinicians should also prioritize vaginal estrogen for women suffering from genitourinary symptoms and consider vaginal lubricants and moisturizers as adjunctive treatments. While the guideline does not focus on the microbiome, the vaginal health benefits of estrogen may support a more favorable vaginal microbiome, emphasizing the importance of managing both symptoms and vaginal ecosystem health concurrently. These considerations should be incorporated into personalized treatment plans for optimal outcomes.