A Review of Treatment Options for Menopause

Both hormonal and non-hormonal therapies are available for treating postmenopausal symptoms.

Menopause is the discontinuation of ovarian function and is marked by 12 consecutive months of amenorrhea. It occurs at a median age of 51 years. Postmenopausal symptoms that can be managed include vasomotor symptoms (VMS), vulvovaginal atrophy, sexual dysfunction, dyspareunia, frequent urination, and osteoporosis. 

A recent study was published in the International Journal of Women’s Health with the goal of providing an overview of menopausal hormone therapy (MHT) and other non-hormonal treatments for postmenopausal women by including the most recent primary research.

Efficacy of Hormonal Combination Therapy With Estrogen and Progesterone

The four indications for MHT that have received FDA approval are vasomotor symptoms (VMS), osteopenia, early hypoestrogenism, and vulvovaginal symptoms. Estrogen MHT is available in oral, transdermal, and vaginal forms. Conjugated equine estrogens (CEE), micronized 17-estradiol, ethinyl estradiol, and conjugated estrogens (CE), are examples of commonly used estrogen formulations. Vaginal rings containing estradiol acetate (12.4 mg or 24.8 mg) are used for local treatment. 

Progestogens, such as micronized progesterone, levonorgestrel, medroxyprogesterone acetate, and norethindrone acetate, are given in combination with estrogen to prevent endometrial cancer. 

New Non-Hormonal Therapy for Vasomotor Symptoms

A novel family of centrally active drugs for the management of VMS is called neurokinin B antagonists. The FDA is now reviewing fezolinetant, an experimental oral neurokinin-3 receptor antagonist, for the treatment of moderate to severe VMS.

Effective Osteoporosis Treatment Alternatives

Hormonal treatment with estrogen is not FDA-approved for osteoporosis. Non-hormonal options include bisphosphonates (oral/IV); denosumab (subcutaneous); parathyroid hormone receptor agonists, including teriparatide and abaloparatide; and the monoclonal antibody romosozumab, to build bone and reduce osteoclastic bone resorption. Also available are selective estrogen receptor modulators (SERMs), such as raloxifene. 

Non-pharmacologic approaches include fall prevention, weight-bearing activity, vitamin D supplementation (600–1,200 IU/day), and a calcium-rich diet (800–1,200 mg/day) for high-risk women.

Risk Factors Associated With Menopausal Hormone Treatment

The Women’s Health Initiative (WHI) studies found that MHT usage increased the risk of breast cancer but reduced the risk of endometrial and colorectal cancer. MHT had no protective effect on cognition, and the risk of probable dementia and cognitive impairment increased when data from the estrogen-progestin and estrogen-only arms were combined. 

Despite the risks, MHT is beneficial for treating vasomotor symptoms, and in younger women (<60 years old) within 10 years of menopause, the benefits may outweigh the risks of coronary heart disease, stroke, and venous thromboembolism. 

There are differences between the results of the WHI and other studies related to risk factors for MHT; therefore, further research is needed to identify novel therapies with reduced long-term health risks.

Source:

Madsen, T. E., Sobel, T., Negash, S., Allen, T. S., Stefanick, M. L., Manson, J. E., & Allison, M. (2023). A Review of Hormone and Non-Hormonal Therapy Options for the Treatment of Menopause. International Journal of Women’s Health, Volume 15, 825–836. https://doi.org/10.2147/ijwh.s379808