Approach to treatment of menopausal symptoms

Question 1

Vasomotor syndromes of menopause (VSM) first question to ask

Answer 1

Age less than or above 60 (within 10 years of menopause)

Question 2

What to do if age is below 60 (within 10 years) and has VSM symptoms

Answer 2

Does she have contraindications to estrogen?
(endometrial or breast cancer, strokes, thromboembolic disorders)

Question 3

What to do if patient does have a contraindication to estrogen

Answer 3

candidate for non hormonal treatment
(SSRIs SNRIs, gabapentinoids,
lifestyle changes)

Question 4

What to do if patient does not have a contraindication to estrogen

Answer 4

Assess CVS risk.
if 0-5%, MHT candidate
If 5-10%, MHT candidate with preference for transdermal treatment

Question 5

What to do after assessing CVS risk?

Answer 5

Uterus present?
If yes, progesterone + estrogen or CEE & bazedoxifene
If no, estrogen monotherapy

Question 6

What do we monitor after MHT

Answer 6

mammograms, bone loss, CVD risk

Question 7

What to do with VSM symptoms if aged above 60 or CVD risk above 10 %

Answer 7

non-hormonal therapy
(SSRIs SNRIs gabapentinoids)

Question 8

First question to ask with genitourinary symptoms

Answer 8

Contraindication to estrogen? If yes, use vaginal lubricants and moisturizers

If no, use vaginal estrogen through creams, rings, and inserts

use DHEA and ospemifene