Medical Management of Menopause Symptoms

Indication for hormone therapy

Systemic hormone therapy should be considered for management of troublesome vasomotor symptoms (hot flashes and night sweats) during perimenopause and menopause^{Footnote 1}  . Despite historical concerns, hormone therapy is safe and effective and is the first line treatment for people younger than 60 years of age or less than 10 years post-menopause without contraindications^{Footnote 1} . Hormone therapy may also be effective in treating other symptoms of menopause, which include brain fog, sleep disturbances and mood changes. See Table 1 for further details

Perimenopausal and menopausal individuals may also experience symptoms such as vaginal dryness, irritation, discomfort during intercourse as well as urinary urgency, dysuria and recurrent urinary tract infections. These symptoms collectively are referred to as the genitourinary syndrome of menopause (GSM)^{Footnote 2}  . For GSM symptoms, first-line therapies include vaginal moisturizers and lubricants whereas second-line therapies consist of local vaginal estrogen preparations (vaginal creams, vaginal tablets or a vaginal ring) (Table 2). Vaginal estrogen preparations are not systemic and therefore do not require progesterone for endometrial protection, even in individuals with a uterus^{Footnote 2}  .

Table 1: Indications and contraindications for systemic hormone therapy

Assessment and diagnosis

Take a careful history to exclude other causes of hot flashes and sleep disturbances, which may include thyroid disorders, medication side effects, mental health issues and chronic pain.

There is no blood test required to diagnose perimenopause or menopause, treatment can be started based on history alone. However routine blood work to screen for risk factors such as cardiovascular disease and diabetes may be warranted^{Footnote 4}  . 

It is important to approach menopause support broadly. Not all individuals who experience menopause will identify as a woman, and gender diverse and transgender members may also be affected by menopause. Menopause may affect younger people and may be the result of surgery or illness. Each person’s experience with menopause will be unique and should be considered during your assessment and treatment plan.

Everyone can be affected by menopause. Some firsthand, and others indirectly both within the workplace and at home. This is an inclusive subject that everyone needs to know about^{Footnote 5} .

Choosing the right regimen

To address the systemic symptoms of perimenopause and menopause, effective management involves the administration of systemic estrogen, whether through transdermal or oral route. Transdermal estrogen is safer, better tolerated and has a lower thrombosis risk profile than oral estrogen. For individuals with a uterus, concurrent progesterone is essential to protect the endometrium, while those without a uterus do not require progesterone for symptom management (Graphic 1).

Hormonal therapy (Continuous or Cyclic):

Continuous combined regimen – Continuous estrogen and progesterone therapy ( Tables 3-5) typically induces amenorrhea in persons who are menstruating. Estrogen and progesterone are usually given separately, but there are combination preparations available with both estrogen and progestin contained in one product. A 52 mg levonorgestrel-releasing intrauterine system (Mirena^®) can also be used as a form of continuous progesterone therapy for endometrial protection.

Commonly prescribed continuous regimen: 17β-estradiol gel (Estrogel), 1 actuation to each arm or conjugated estrogen (Premarin), 0.625mg tablets, once daily. For individuals with a uterus Micronized progesterone (Prometrium) 100mg at bedtime or a 52 mg levonorgestrel-releasing intrauterine system (Mirena^®) needs to be added^{Footnote 6} .

Cyclic Regimen – For individuals in the perimenopausal stage who are still experiencing menstruation, a continuous treatment plan may result in unpredictable bleeding. For such individuals, we suggest opting for a cyclic regimen for example: continuous/daily administration of transdermal or oral estrogen and cyclic administration of oral micronized progesterone (200mg per day for 12 – 14 days of each calendar month) ( Table 4).^{Footnote 6}  

Non-hormonal therapy

When non-hormonal therapy is recommended or preferred, venlafaxine is typically the initial consideration, starting at 37.5mg daily for one week, then increase to 75mg daily^{Footnote 1} .

Starting dose and adjustments of hormone therapy

Standard dosing for estrogen and progesterone are included in Tables 3 - 5. Typically, relief from hot flashes is experienced within the initial three to four weeks of treatment. In cases where bothersome hot flashes persist beyond this period, increasing the estrogen dose is appropriate. For individuals with severe symptoms, initiating therapy at a higher estrogen dose is recommended for more prompt relief, such as starting doses of 1.25mg of conjugated estrogen or 3-4 actuations of transdermal estradiol. If higher doses of estrogens are used, higher doses of progestogens should also be used^{Footnote 1} . The goal is to have the lowest doses possible that obtain symptom relief.

Tapering

If vasomotor symptoms are alleviated and the hormone therapy is well-tolerated, the same regimen may be maintained over several years. While there is no definitive restriction on the duration of menopause hormone therapy, it is customary to wait at least five years before considering the initial taper. The taper's objective may be to reduce the dosage rather than cease hormone therapy entirely. Factors like patient age, cardiovascular risk, additional benefits such as preventing bone loss, and collaborative decision-making should all be carefully considered in this context^{Footnote 1} .

Non-hormone systemic therapies found in Table 6 will often require tapering of the medication when discontinuing.

Side effects and troubleshooting of hormone therapy

Vaginal bleeding: Unscheduled bleeding is the most common side effect for persons on hormone therapy. Some vaginal bleeding for up to 6 months after initiating hormone therapy is acceptable. If bleeding is heavy, frequent or persists beyond 6 months, investigations, such as endometrial biopsy, should be initiated. Consideration should be given to inserting a Mirena^® IUS to prevent unscheduled bleeding, once investigated^{Footnote 4} .

Mood changes: Persons who experience depression or irritability with the use of progestogens may benefit from changing the type of progesterone or regimen (cyclic versus continuous)^{Footnote 4} .

Headaches: Frequency and severity of migraines may fluctuate with hormone levels. Migraines may improve with the use of transdermal estrogen and micronized progesterone. Individuals who experience migraine headaches with auras have an increased risk of stroke. If migraines or auras worsen while on hormone therapy, the dose should be decreased, or the medications discontinued^{Footnote 4} . 

The following tables provide details on the type of therapy, dosing and additional information that may be helpful when treating symptoms of perimenopause and menopause. Note that if a checkmark is located in the first column, this indicates that the medication is available in the CAF Drug Benefit List as a regular benefit. 

Table 2: Treatment options for genitourinary symptoms

NOTE: All vaginal estrogens help to decrease urinary tract infections

Table 3: Systemic estrogen hormone therapy availability and dosing

*NOTE: If using high dose systemic estrogen, consider using a Mirena^® IUS for endometrial protection for persons with an intact uterus which can reduce the risk of abnormal uterine bleeding

Table 4: Progesterone hormone dosing for continuous and cyclic therapy

Table 5: Combination hormone therapy availability and dosing

Table 6: Non-hormone therapy options for vasomotor symptoms

*Clonidine is the only non-hormone medication approved by Health Canada for treatment of vasomotor symptoms. All the other medications included in this table are being used off label.