During Women's Health Awareness Month, it is crucial to address menopause-related issues with informed strategies. The prevalence of vasomotor symptoms of menopause ranges from 50% to 82% among US women experiencing natural menopause. Additionally, genitourinary syndrome of menopause affects 27% to 84% of postmenopausal women. Breast cancer impacts approximately one in eight women in the US.
In this article, we dive into a comprehensive analysis of major clinical practice guidelines and other guidance documents published by the North American Menopause Society (NAMS), American College of Obstetricians and Gynecologists (ACOG), Endocrine Society (ES), American Association of Clinical Endocrinologists (AACE), and American College of Endocrinology (ACE). By comparing and contrasting their approaches, we aim to shed light on best practices for the diagnosis and management of symptoms of menopause, highlighting the importance of harmonized guidelines to ensure effective and compassionate care for women undergoing menopause
Guideline Synopsis
North American Menopause Society (NAMS)
- Genitourinary Syndrome of Menopause Position Statement
- Published: September 2020
- Target Population: Menopausal women
- Grades Strength of Recommendation: Yes
- Grades Level of Evidence: No
- Based on Systematic Review: No
- Goal: The goal is “to update and expand the 2013 position statement of The North American Menopause Society (NAMS) on the management of the genitourinary syndrome of menopause (GSM), of which symptomatic vulvovaginal atrophy (VVA) is a component.”
- Literature Search Through: Not reported but implied to be from the last version 2013 up to 2020
- Included Internal Review: Yes
- Included External Review: No
- Discloses Funding Source and COIs: Yes
North American Menopause Society (NAMS) and The International Society for the Study of Women’s Sexual Health (ISSWSH)
- Management Of Genitourinary Syndrome of Menopause in Women with or at High Risk for Breast Cancer
- Published: June 2018
- Target Population: Menopausal women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease
- Grades Strength of Recommendation: Yes
- Grades Level of Evidence: No
- Based on Systematic Review: No
- Goal: The goal is to “create a point of care algorithm for treating genitourinary syndrome of menopause (GSM) in women with or at high risk for breast cancer.”
- Literature Search Through: Not reported in the main document
- Included Internal Review: Yes
- Included External Review: No
- Discloses Funding Source and COIs: Yes
American College of Obstetricians and Gynecologists (ACOG)
- Practice Bulletin for the Management of Menopausal Symptoms
- Published January 2014
- Target Population: Menopausal women
- Grades Strength of Recommendation: Yes
- Grades Level of Evidence: Yes
- Based on Systematic Review: No
- Goal: The goal Is “to provide evidence-based guidelines for the treatment of vasomotor and vaginal
- symptoms related to natural and surgical menopause.”
- Literature Search Through: Through April 2013
- Included Internal Review: No
- Included External Review: No
- Discloses Funding Source and COIs: No
Endocrine Society (ES)
- Clinical Practice Guideline for the Treatment of Symptoms of the Menopause
- Published November 2015
- Target Population: Menopausal women
- Grades Strength of Recommendation: Yes
- Grades Level of Evidence: Yes
- Based on Systematic Review: Yes
- Goal: The goal is to “generate a practice guideline for the management
- and treatment of symptoms of the menopause.”
- Literature Search Through: Not reported in the main document
- Included Internal Review: Yes
- Included External Review: Yes
- Discloses Funding Source and COIs: Yes
American Association of Clinical Endocrinologists (AACE) And American College of Endocrinology (ACE)
- Position Statement on Menopause
- Published July 2017
- Target Population: Menopausal women
- Grades Strength of Recommendation: No
- Grades Level of Evidence: No
- Based on Systematic Review: No
- Goal: The goal is to “update the previous menopause clinical practice guidelines published in 2011 but does not replace them.”
- Literature Search Through: Not reported but implied to be from the last version 2011 up to 2017
- Included Internal Review: No
- Included External Review: No
- Discloses Funding Source and COIs: Yes
North American Menopause Society (NAMS)
- The 2022 hormone therapy position statement
- Published July 2022
- Target Population: Menopausal women
- Grades Strength of Recommendation: Yes
- Grades Level of Evidence: Yes
- Based on Systematic Review: No
- Goal: The goal is to “update The 2017 Hormone Therapy Position Statement of The North American Menopause Society”
- Literature Search Through: Not reported but implied to be from the last version of 2017 up to 2022
- Included Internal Review: Yes
- Included External Review: No
- Discloses Funding Source and COIs: Yes
North American Menopause Society (NAMS)
- Nonhormonal Management of Menopause-Associated Vasomotor Symptoms
- Published June 2023
- Target Population: Menopausal women
- Grades Strength of Recommendation: Yes
- Grades Level of Evidence: Yes
- Based on Systematic Review: No
- Goal: The goal is to “ update the evidence-based Nonhormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society.”
- Literature Search Through: Not reported but implied to be from the last version 2015 up to 2013
- Included Internal Review: Yes
- Included External Review: No
- Discloses Funding Source and COIs: Yes
Guideline Similarities
The following are agreed upon in the current guidelines:
For GSM:
- the need for healthcare providers to take the initiative and ask about GSM
- using the opportunity when women present during the menopausal transition to perform evaluation and assessment
- evaluation of GSM should include screening, history taking, and physical examination
- over-the-counter (OTC) non-hormonal vaginal lubricants and moisturizers as the first-line treatment for GSM for women with or without breast cancer versus an informed-consent discussion of breast cancer risk for women who prefer hormone therapy
- low-dose vaginal estrogen, ospemifene, vaginal moisturizers, and lubricants as effective therapy for those choosing non-hormonal therapy
- local hormone therapy for the treatment of women with only vaginal symptoms without vasomotor symptoms
- education about GSM
- the importance of communicating the potential benefits and risks of hormone therapy and other therapies with the patients.
For menopausal vasomotor symptoms:
- Systemic hormone therapy (HT), also called menopausal hormone therapy (MHT), is the most effective therapy.
- Before starting HT, healthcare providers should screen women for cardiovascular and breast cancer risk.
- Healthcare providers should individualize care when prescribing HT.
- For women aged younger than 60 years or who are within 10 years of menopause and have no contraindications, the benefit-risk ratio is favorable for the treatment of bothersome VMS and also for the prevention of bone loss.
- For women who initiate hormone therapy more than 10 years from menopause onset or who are older than 60 years, the benefit-risk ratio appears less favorable. Longer durations of therapy should be for documented indications such as persistent VMS, with shared decision-making and regular reevaluation.
- Data do not show that herbal supplements are efficacious.
Guideline Differences
Potential Reasons for Differences
- Differences in the specific scope of each guideline—menopausal vasomotor symptoms, or GSM.
- Some guidance documents are created by a single society and others by a collaboration between societies.
- Differences in the methodology used to formulate the recommendations.
- The publication dates.
- The target population — menopausal women with or without risk of breast cancer.
Specific Guideline Differences
- The term GSM is new, so it is not used in older guidelines (before 2015)
- For treatment of GSM in women with or at risk of breast cancer, NAMS/ISSWSH recommends the use of local hormone therapy for some women who fail nonhormone treatments after a discussion of risks and benefits and review with a woman’s oncologist. In women who present with symptomatic GSM 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 oncologist to discuss using low-dose vaginal ET. While NAMS 2020 reported that there is insufficient data at the time of publication to confirm the safety of vaginal estrogen or DHEA or ospemifene in women with breast cancer, the management of GSM should consider the recommendations of her oncologist.
- NAMS 2023 does not recommend cooling techniques, but ACOG recommends common sense lifestyle modification such as clothing layering, maintaining a lower ambient temperature, and drinking cool drinks. Also, ES recommends turning down the thermostat and dressing in layers.
| General Comparison of Key Components in Each Guideline | |||
| Details | GSM/ vaginal symptoms | Menopausal vasomotor Symptoms | Women with or at risk for breast cancer |
| NAMS 2020 | Yes | No | Yes, in some recommendations only |
| NAMS/ISSWSH | Yes | No | Yes, as the target population |
| ACOG | Yes | Yes | No, but it recommended referral to ACOG Practice Bulletin number 126 |
| ES | Yes | Yes | Yes, in some recommendations |
| AACE/ACE | Yes | Yes | Yes, in some recommendations |
| NAMS 2022 | Yes | Yes | Yes, in some recommendations |
| NAMS 2023 | No | Yes | Yes, in some recommendations only |
General Comparison of Key Conclusions in Each Guideline
NAMS 2020
- Nonhormone therapies without a prescription provide sufficient relief for most women with mild symptoms.
- Low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are effective for moderate to severe GSM.
- When low-dose vaginal estrogen, DHEA, or ospemifene is administered, a progestogen is not indicated. However, endometrial safety has not been studied in clinical trials beyond 1 year.
- There is insufficient data to confirm the safety of vaginal estrogen, DHEA, or ospemifene in women with breast cancer.
- The management of GSM should consider the woman’s needs and include a discussion with her oncologist.
NAMS/ISSWSH
- Nonhormone treatments generally are the first line.
- Local hormone therapies may be an option for some women who fail non-pharmacologic and non-hormone treatments after a discussion of risks and benefits and review with an oncologist.
ACOG
- Systemic HT is the most effective therapy for vasomotor symptoms related to menopause.
- Low and ultra-low systemic doses of estrogen are associated with a better adverse effect profile.
- HT treatment with the lowest effective dose for the shortest duration that is needed to relieve vasomotor symptoms is recommended.
- The risks of combined systemic HT include thromboembolic disease and breast cancer.
- SSRIs, SSNRIs, clonidine, and gabapentin are effective alternatives for the treatment of menopausal vasomotor symptoms.
- Estrogen therapy alleviates atrophic vaginal symptoms.
- Local therapy is advised for the treatment of women with only vaginal symptoms.
- Paroxetine is the only nonhormonal therapy that is approved by the FDA for the treatment of vasomotor symptoms.
- The FDA approved ospemifene for treating moderate-to-severe dyspareunia in postmenopausal women.
ES
- Menopausal hormone therapy is the most effective treatment for vasomotor symptoms and other symptoms of the climacteric.
- Benefits may exceed risks for the majority of symptomatic postmenopausal women who are under age 60 or under 10 years since the start of menopause.
- Healthcare professionals should individualize therapy.
- Women should be screened for cardiovascular and breast cancer risk before initiating MHT.
- Current evidence does not justify the use of MHT to prevent coronary heart disease, breast cancer, or dementia.
- Other options are available for those with vasomotor symptoms who prefer not to use MHT or who have contraindications.
- Low-dose vaginal estrogen and ospemifene provide effective therapy for the genitourinary syndrome of menopause; vaginal moisturizers and lubricants are available for those not choosing hormonal therapy.
- All postmenopausal women should embrace appropriate lifestyle measures.
AACE/ACE
- The use of menopausal hormone therapy in symptomatic postmenopausal women should be based on consideration of all risk factors for cardiovascular disease, cancer, osteoporosis, age, and time from menopause.
- The use of transdermal as compared with oral estrogen preparations may be considered less likely to produce thrombotic risk and perhaps the risk of stroke and coronary artery disease.
- When the use of progesterone is necessary, micronized progesterone is considered the safer alternative.
- In symptomatic menopausal women who are at significant risk from the use of hormone replacement therapy, the use of selective serotonin re-uptake inhibitors and possibly other nonhormonal agents may offer significant symptom relief.
- In women with previously diagnosed diabetes, the use of HRT should be individualized.
NAMS 2022
- Hormone therapy remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause.
- The risks of hormone therapy differ.
- The benefit-risk ratio is favorable for treatment of bothersome VMS and prevention of bone loss in women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, Nevertheless, treatment should be individualized.
- For women who start hormone therapy more than 10 years after menopause or who are older than 60 years, the benefit-risk ratio appears less favorable.
- If GSM symptoms are not relieved with over-the-counter therapies in women without indications for the use of systemic hormone therapy, low-dose vaginal estrogen therapy or other treatment (e.g., vaginal dehydroepiandrosterone or oral ospemifene) are recommended.
NAMS 2023
- Hormone therapy is the most effective treatment for vasomotor symptoms and should be considered in menopausal women within 10 years of the last menstrual period.
- For women who are not candidates for hormone therapy or personal preference, nonhormone treatment options are available.
- Examples: cognitive-behavioral therapy, clinical hypnosis, selective serotonin reuptake inhibitors/ serotonin-norepinephrine reuptake inhibitors, gabapentin, fezolinetant; oxybutynin; weight loss, stellate ganglion block.
| Specific Testing Recommendations | |
| Testing | Replicate measures of follicle-stimulating hormone (FSH) and serum estradiol. |
| NAMS 2020 | Not mentioned |
| NAMS/ISSWSH | Not mentioned |
| ACOG | Not mentioned |
| ES | Yes, if establishing a diagnosis of menopause is necessary for patient management in women undergone hysterectomy without bilateral oophorectomy or presenting with a menstrual history that is inadequate to ascertain menopause |
| AACE/ACE | Not mentioned |
| NAMS 2022 | Not mentioned |
| NAMS 2023 | Not mentioned |
Management
- The genitourinary syndrome of menopause (GSM) was covered in six guidance documents and the vasomotor symptoms were covered in five guidance documents. The management recommendations for each are summarized in the following two tables.
Specific Management Recommendations for GSM/vaginal symptoms
| Management | NAMS 2020 Genitourinary Syndrome of Menopause Position Statement | NAMS/ISSWSHManagement Of Genitourinary Syndrome of Menopause in Women with or at High Risk for Breast Cancer | ACOG Practice Bulletin for the Management of Menopausal Symptoms | ESClinical Practice Guideline for the Treatment of Symptoms of the Menopause | AACE/ACE Position Statement on Menopause | NAMS 2022The 2022 hormone therapy position statement |
| OTC nonhormone vaginal lubricants and moisturizers | Recommended as first-line treatment | Yes, as first-line treatment | Water-based or silicone-based vaginal lubricants and moisturizers may alleviate the symptoms. | Yes | Not mentioned | Not mentioned |
| Self-stimulators/ Vibrators | Not mentioned | PRN | Not mentioned | Not mentioned | Not mentioned | Not mentioned |
| Pelvic floor physical therapy | Beneficial | Recommended as first-line treatment. | Not mentioned | Not mentioned | Not mentioned | Not mentioned |
| Dilator therapy | “…may reduce GSM symptoms” | Recommended as first-line treatment | Not mentioned | Not mentioned | Not mentioned | Not mentioned |
| Low-dose vaginal estrogen | Yes, preferred over systemic therapy when there are no other symptoms that require systemic therapy/ for women with moderate to severe symptoms or those who donot respond to lubricants and moisturizers | Local hormone therapy is reasonable for some women who have failed nonhormone treatment after clearance from an oncologist. | Yes, local therapy is recommended for women with only vaginal symptoms. | Effective for women without a history of hormone- (estrogen) dependent cancers who are seeking relief from symptoms that persist despite using vaginal lubricants and moisturizers. Women with a history of cancer, require shared decision-making with the oncologist | The discussion does, but the Recommendations do not, list specific indications for treatment. | Yes, if symptoms are not relieved with nonhormone therapies.For women with breast cancer, low-dose vaginal estrogen shouldbe prescribed in consultation with their oncologists |
| Vaginal dehydroepiandrosterone (DHEA) | Effective for women with moderate to severe symptoms or those who do not respond to lubricants and moisturizers | Local hormone therapy is reasonable for some women who have failed nonhormone treatment after clearance from an oncologist | Not mentioned | Not mentioned | The discussion does, but the Recommendations do not, list specific indications for treatment. | Yes, if symptoms are not relieved with nonhormone therapies |
| Ospemifene, an oral Selective Estrogen-Receptor Modulator(SERM) | FDA-approved for women with moderate to severe symptoms or those who do not respond to lubricants and moisturizers | Ospemifene is not FDA-approved for use in women with or at high risk for breast cancer. | FDA-approved for moderate-to-severe dyspareunia | Effective for moderate to severe dyspareunia without contraindications. However, it is not recommended for women with a history of breast cancer | The discussion does, but the Recommendations do not, list specific indications for treatment. | Yes, if symptoms are not relieved with nonhormone therapies |
| Energy-based therapieslasers(fractional CO2, Erbium:YAG) and radio-frequency devices | require safety and efficacy studies | Laser therapy may be considered in women who prefer nonhormone therapy after informing about the lack of long-term safety and efficacy data. | Not mentioned | Not mentioned | Not mentioned | Not mentioned |
| Topical lidocaine | Not in the main recommendation but was mentioned in the text as among “treatment considerations for women with breast cancer” | “Can be used as an adjunct to other therapies…” | Not mentioned | Not mentioned | Not mentioned | Not mentioned |
| Testosterone | Not in the main recommendations but was mentioned in the text. “Longer and larger studies are needed to assess safety and efficacy. “ | “Off-label use of compounded vaginal testosterone or estriol is not recommended” | Not mentioned for GSM specifically | Not mentioned | Testosterone was mentioned in passing with no referral to indications.“The most recent version of the AACE/ACE menopause guidelines cautioned against the use of bioidentical hormone replacement.” (Table 3). | Mentioned only in combination ET.Bioidentical hormone therapy is not recommended. |
| Progestogens | Not recommended with low-dose vaginal ET. Women at increased risk of endometrial cancer may need endometrial surveillance. | Not mentioned | Data do not support the use of testosterone for VMS. | For women using low-dose vaginal ET, no need foradding a progestogen to prevent endometrial hyperplasia. | Progestins are mentioned many times in the text but only once in the Recommendations: “When the use of progesterone is necessary, micronized progesterone is considered the safer alternative. “ | No, progestogen is not required with low-dose vaginal estrogen. |
| Systemic estrogen therapy (ET) variously known as hormone therapy (HT), estrogen plus progestogen therapy (EPT) and menopausal hormone therapy (MHT) | Yes, when VMS are also present | “…discouraged for women with a history of or at high risk for breast cancer.” | “Systemic HT, with estrogen alone or in combination with progestin, is the most effective therapy for vasomotor symptoms related to menopause. | Not mentioned specifically for GSM. | One Recommendation identifies systemic estrogens as more likely to produce thrombotic risk and perhaps the risk of stroke and coronary artery disease.” Mentioned numerous times in the article related to indications, benefits, risks and adverse events.“The combination of SERM [bazedoxifene/CEE [conjugated equine estrogen] decreased the incidence of hot flashes and improved vaginal dryness compared with SERM alone.”“Sexual desire was minimally better with estradiol [0.5 mg] than SSRI treatment, while venlafaxine was better than estradiol for therapy of anorgasmia, pain, and vaginal dryness. | Effective for sexual function, but systemic hormone therapy does not improve urinary incontinence and may increase the incidence of stress urinary incontinence. |
Specific Management Recommendations for Vasomotor Symptoms
| Management | ACOG Practice Bulletin for the Management of Menopausal Symptoms | ESClinical Practice Guideline for the Treatment of Symptoms of the Menopause | AACE/ACE Position Statement on Menopause | NAMS 2022The 2022 hormone therapy position statement | The 2023 nonhormone therapy position statement |
| Systemic HT, with estrogen alone or in combination with progestin | “Systemic HT, with estrogen alone or in combination with progestin, is the most effective therapy for vasomotor symptoms related to menopause. “ | Effective for menopausal women 60 years old or 10 years after menopause with bothersome VMS, without contraindications or cardiovascular or breast cancer risks, and are willing to take HT—estrogen therapy (ET) for those without a uterus and estrogen plus progestogen therapy (EPT) for women with a uterus. | Mentioned in Recommendations only generally as hormonal therapy. | Recommended for women younger than 60 years or within 10 years of menopause onset and with no contraindications, the benefit-risk ratio is favorable for treatment of bothersome VMS and for the prevention of bone loss and reduction of fracture | Hormone therapy is the most effective treatment for vasomotor symptoms and should be considered in menopausal women within 10 years of the final menstrual periods” (although no specific recommendations since it is out of the document's scope) |
| Selective serotonin reuptake inhibitors (SSRIs) | “...the antidepressant agents SSRIs and SSNRIs are effective for the treatment of vasomotor symptoms associated with menopause.” | Recommended | Effective for hot flashes but contraindicated with tamoxifen. | Not mentioned | “Evidence exists that SSRIs and SNRIs are associated with mildto moderate improvements in VMS.” |
| Paroxetine (an SSRI) | “Paroxetine is the only nonhormonal therapy that is FDA approved for the treatment of vasomotor symptoms | Low-dose paroxetine mesylate is the only FDA-approved agent in this class.Caution is advised for the use of paroxetine in patients taking tamoxifen | In breast cancer patients, fluoxetine and paroxetineshould not be used, since they inhibit the effect oftamoxifen | Not mentioned | “… significantly reduce[s] VMS in symptomatic menopausalwomen. |
| Selectiveserotonin-norepinephrine reuptake inhibitors (SSNRIs)/ SNRIs | Effective alternative to HT | Recommended | Not mentioned | Not mentioned | “Evidence exists that SSRIs and SNRIs are associated with mildto moderate improvements in VMS.” |
| Clonidine, active α-2 adrenergic agonist | Effective alternative to HT | Suggested if there are no contraindications and other nonhormonal treatments have failed. | Effective for hot flashes | Not mentioned | Not recommended. “…less beneficial than SSRIs, SNRIs, and gabapentin in reducingVMS. |
| Gabapentin | Effective alternative to HT | Gabapentin or pregabalin are suggested if there are no contraindications. | Gabapentin and pregabalin are effective for hot flashes | Not mentioned | Gabapentinoids are Recommended |
| Fezolinetant | Not mentioned | Not mentioned | Not mentioned | Not mentioned | Recommended: |
| Oxybutynin | Not mentioned | Not mentioned | Not mentioned | Not mentioned | Recommended: |
| Stellate ganglion block | “ additional studies are needed to assess the safety and effectiveness of this novel technique.” | Requires further study | Not mentioned | Not mentioned | Recommended: |
| Herbs | Data do not show they are efficacious. | Counseling is suggested due to a lack of consistent evidence | For breast cancer survivors, phytoestrogens, black cohosh and St. John’s wort should not be used to treat hot flashes | Not mentioned | Supplements and herbs are not recommended |
| Progestin-only, testosterone, or compounded bioidentical hormones | Data do not support the use. | A progestogen is recommended for desired MHT when VTE risk is elevated.Custom-compoundedHormones are not recommended. | "Micronized progesterone is considered the safer alternative. "Testosterone is mentioned only in terms of risk. Bioidentical hormone therapy is not recommended. | “When the use of progesterone is necessary, micronized progesterone is considered the safer alternative.”Bioidentical hormone therapy is not recommended. | Not mentioned |
| Conjugated (combined) equine estrogens (CEE) | It is mentioned in the text. The document also mentioned the risk. “The Women’s Health Initiative (WHI) study, a large RCT of healthy menopausal women aged 50–77 years, demonstrated a slightly increased risk of breast cancer, coronary heart disease, stroke, and venous thromboembolic events and a decreased risk of fractures and colon cancer after an average of 5 years of combined HT”Local vaginal estradiol and local conjugated equine estrogen…are effective in treating atrophic vaginitis.”. | Recommended with bazedoxifene for symptomatic women with a uterus and without contraindications. | Mentioned only as cardiovascular risk | The document mentioned the benefits and risks (in figure 1) of the two hormone therapy formulations, conjugated equine estrogens (CEE) alone or in combination with medroxyprogesterone acetate (MPA), evaluated in the Women’s Health Initiative. | Not mentioned |
| Tibolone, a synthetic steroid | Tibolone is not FDA-approved and is not available in the United States.It appears to have a beneficial effect on bone density, vasomotor symptoms, and vaginal symptoms without estrogenic effects on the uterus or breasts. However, given its limited safety and efficacy data compared with HT, tibolone is not considered a first-line therapy. | Effective for women with bothersome VMS and climacteric symptoms and without contraindications as an alternative but not as an addition to other forms of HT. It is not recommended in women with a history of breast cancer. | Not mentioned | Not mentioned | Not mentioned |
Key Takeaways
- Screening and assessment of GSM should consist of history taking, physical examination, and excluding similar conditions.
- Counseling patients about treatment options for GSM should include shared decision-making.
- First-line non-hormonal treatment to alleviate the symptoms of mild GSM includes over-the-counter (OTC) nonhormone vaginal lubricants and moisturizers.
- Low-dose vaginal estrogen and ospemifene provide effective therapy for the GSM of menopause.
- For vasomotor symptoms, menopausal hormone therapy (MHT)/systemic hormone therapy (HT) with estrogen alone or in combination with progestin is the most effective treatment.
- Before initiating MHT, healthcare providers should screen women for cardiovascular and breast cancer risk.
- Other options are available for those with vasomotor symptoms who should not or wish not to take MHT.
- For women aged younger than 60 years or who are within 10 years of menopause onset and have no contraindications, the benefit-risk ratio is favorable for treatment of bothersome VMS and prevention of bone loss.
- For women who start hormone therapy more than 10 years from menopause onset or who are older than 60 years, the benefit-risk ratio appears less favorable because of the greater risks of coronary heart disease, stroke, venous thromboembolism, and dementia.
- In breast cancer patients, fluoxetine and paroxetine should not be used, as they inhibit the effect of tamoxifen. Other guidelines recommend experiencing caution of paroxetine in patients taking tamoxifen.
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