The American College of Obstetricians and Gynecologists has published an updated guideline for the management of menopausal symptoms, the first update since 2001. The guideline recommends systemic hormone therapy, either estrogen alone or in combination with a progestin, as the most effective treatment for vasomotor symptoms, the most common menopausal symptom, affecting 50-82% of women. Low-dose or ultra low-dose estrogen is recommended for the shortest duration necessary, although most women experience vasomotor symptoms, especially hot flashes, for 4-10 years. Conjugated equine estrogen and medroxyprogesterone were found in the Women’s Health Initiative Study to increase the risk of breast cancer and thromboembolic events. Transdermal estrogen appears to be safer than oral forms of the drug. The guideline also states that treatment can be extended past age 65 because vasomotor symptoms may persist. The guideline also recommends estrogen in combination with the recently approved selective estrogen receptor modulator (SERM) bazedoxifene in place of a progestin. For women who are unable or unwilling to take hormone-based treatments, selective serotonin reuptake inhibitors (SSRIs) may be helpful, although paroxetine is the only agent currently approved for this indication. SSNRIs, gabapentin, and clonidine may also be useful, but have not been evaluated by the FDA for treatment of vasomotor symptoms. Hormone-based therapy is also effective for vaginal dryness as is the recently approved SERM ospemifene (Osphena). There is not enough evidence to support the use of bioidentical hormones, phytoestrogens, herbal remedies, or even exercise (Obstet Gynecol 2014;123:202-216).
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