Chapter 55: Menopause – Hormonal & Nonhormonal Therapies

The chapter on Menopause provides comprehensive guidance for diagnosing and managing the consequences of permanent ovarian failure, which results in the failure to produce estrogen, specifically 17-beta-estradiol. This physiological change leads to declining hormone levels and subsequent increases in follicle-stimulating hormone (FSH). The primary symptom clusters requiring management are Vasomotor Symptoms (VMS), such as hot flashes, night sweats, insomnia, and mood changes, and the Genitourinary Syndrome of Menopause (GSM), which includes chronic and progressive symptoms like vulvovaginal atrophy, dryness, and dyspareunia. The goal of drug therapy is to reduce symptom frequency and severity, thereby improving quality of life, but hormone therapy (HT) should not be prescribed to prevent chronic diseases. HT remains the most effective modality for VMS and GSM, offering a significant reduction in hot flash frequency and intensity. Systemic estrogen therapy requires the addition of a progestin in women with an intact uterus to prevent the risk of endometrial hyperplasia and cancer. However, HT carries risks, including increased incidence of venous thromboembolism (VTE), stroke, and invasive breast cancer, particularly if initiated in women over the age of 60 or more than 10 years after menopause onset. For localized GSM symptoms, low-dose topical vaginal estrogen products are highly effective and are advised due to reduced systemic effects. The chapter also explores non-hormonal pharmaceutical alternatives, such as Tissue Selective Estrogen Complexes (TSECs), like bazedoxifene combined with conjugated equine estrogen (CEE) (Duavee), which treats VMS without requiring a progestin, as well as the FDA-approved SSRI paroxetine (Brisdelle), gabapentin, and clonidine. Nonpharmacologic strategies are also important, including smoking cessation, weight loss, reducing caffeine/alcohol/refined carbohydrates, and encouraging regular sexual activity to help manage GSM. Treatment duration must be individualized, with annual reevaluation, and discontinuation should be done gradually to avoid symptom rebound.