Practice Bulletin No. 141: Management of Menopausal Symptoms

Vasomotor and vaginal symptoms are cardinal symptoms of menopause. Vasomotor symptoms can be particularly troubling to women and are the most commonly reported menopausal symptoms, with a reported prevalence of 50-82% among U.S. women who experience natural menopause (1, 2). The occurrence of vasomotor symptoms increases during the transition to menopause and peaks approximately 1 year after the final menstrual period (3-5). The purpose of this document is to provide evidence-based guidelines for the treatment of vasomotor and vaginal symptoms related to natural and surgical menopause. (Treatment of menopausal symptoms in cancer survivors is discussed in the American College of Obstetricians and Gynecologists' Practice Bulletin Number 126, Management of Gynecologic Issues in Women With Breast Cancer.)

[1]  A. Lethaby,et al.  Local oestrogen for vaginal atrophy in postmenopausal women. , 2016, The Cochrane database of systematic reviews.

[2]  J. Gallagher,et al.  Bazedoxifene + conjugated estrogens in HT for the prevention of osteoporosis and treatment of vasomotor symptoms associated with the menopause , 2013, Expert opinion on pharmacotherapy.

[3]  Lewis H Kuller,et al.  Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. , 2013, JAMA.

[4]  J. Manson,et al.  Self-reported menopausal symptoms, coronary artery calcification, and carotid intima-media thickness in recently menopausal women screened for the Kronos early estrogen prevention study (KEEPS). , 2013, Fertility and sterility.

[5]  D. Archer,et al.  Maintenance of the efficacy of desvenlafaxine in menopausal vasomotor symptoms: a 1-year randomized controlled trial , 2012, Menopause.

[6]  M. Leach,et al.  Black cohosh (Cimicifuga spp.) for menopausal symptoms. , 2012, The Cochrane database of systematic reviews.

[7]  N. Panay,et al.  Randomized placebo- and active-controlled study of desvenlafaxine for menopausal vasomotor symptoms , 2012, Climacteric : the journal of the International Menopause Society.

[8]  P. Nyirjesy,et al.  Chronic Vulvovaginitis in Women Older Than 50 Years: Analysis of a Prospective Database , 2012, Journal of lower genital tract disease.

[9]  K. Matthews,et al.  Are vasomotor symptoms associated with alterations in hemostatic and inflammatory markers? Findings from the Study of Women's Health Across the Nation , 2011, Menopause.

[10]  M. Tancer,et al.  Escitalopram treatment of menopausal hot flashes , 2011, Menopause.

[11]  H. Bahrami-Taghanaki,et al.  Menopause-related symptoms: traditional Chinese medicine vs hormone therapy. , 2011, Alternative therapies in health and medicine.

[12]  Hui Lin,et al.  Duration of Menopausal Hot Flushes and Associated Risk Factors , 2011, Obstetrics and gynecology.

[13]  C. Loprinzi,et al.  Multicenter, randomized, cross-over clinical trial of venlafaxine versus gabapentin for the management of hot flashes in breast cancer survivors. , 2010, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[14]  R. Nappi,et al.  Women's voices in the menopause: results from an international survey on vaginal atrophy. , 2010, Maturitas.

[15]  S. Crawford,et al.  Association of Menopausal Vasomotor Symptoms With Increased Bone Turnover During the Menopausal Transition , 2010, Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research.

[16]  T. Rebbeck,et al.  Effect of hormone metabolism genotypes on steroid hormone levels and menopausal symptoms in a prospective population-based cohort of women experiencing the menopausal transition , 2010, Menopause.

[17]  J. Sloan,et al.  Phase III, placebo-controlled trial of three doses of citalopram for the treatment of hot flashes: NCCTG trial N05C9. , 2010, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[18]  C. Fernandes,et al.  Effect of abrupt discontinuation versus gradual dose reduction of postmenopausal hormone therapy on hot flushes , 2010, Climacteric : the journal of the International Menopause Society.

[19]  S. Pruthi,et al.  Managing aromatase inhibitors in breast cancer survivors: not just for oncologists. , 2010, Mayo Clinic proceedings.

[20]  P. Chedraui,et al.  Gabapentin vs. low-dose transdermal estradiol for treating post-menopausal women with moderate to very severe hot flushes , 2010, Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology.

[21]  I. Fentiman,et al.  What can be done about hot flushes after treatment for breast cancer? , 2010, Climacteric : the journal of the International Menopause Society.

[22]  M. Hammar,et al.  A randomized controlled study of taper-down or abrupt discontinuation of hormone therapy in women treated for vasomotor symptoms , 2010, Menopause.

[23]  C. Castelo-Branco,et al.  The role of intranasal estradiol spray in the management of moderate to severe vasomotor symptoms in menopausal women , 2009, Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology.

[24]  G. Bachmann,et al.  Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women: results from a pivotal phase 3 study , 2009, Menopause.

[25]  H. Burger,et al.  Effects of a combination of Hypericum perforatum and Vitex agnus-castus on PMS-like symptoms in late-perimenopausal women: findings from a subpopulation analysis. , 2009, Journal of alternative and complementary medicine.

[26]  A. Daley,et al.  Exercise to reduce vasomotor and other menopausal symptoms: a review. , 2009, Maturitas.

[27]  R. Nappi,et al.  Menopause and sexuality: prevalence of symptoms and impact on quality of life. , 2009, Maturitas.

[28]  R. Verreault,et al.  Effects of Hypericum perforatum (St. John's wort) on hot flashes and quality of life in perimenopausal women: a randomized pilot trial , 2009, Menopause.

[29]  G. Constantine,et al.  A double-blind, randomly assigned, placebo-controlled study of desvenlafaxine efficacy and safety for the treatment of vasomotor symptoms associated with menopause. , 2009, American journal of obstetrics and gynecology.

[30]  M. Lee,et al.  Acupuncture for treating menopausal hot flushes: a systematic review , 2009, Climacteric : the journal of the International Menopause Society.

[31]  F. Hiemeyer,et al.  Micro-dose transdermal estradiol for relief of hot flushes in postmenopausal Asian women: a randomized controlled trial , 2009, Climacteric : the journal of the International Menopause Society.

[32]  C. Labrie,et al.  Effect of one-week treatment with vaginal estrogen preparations on serum estrogen levels in postmenopausal women , 2009, Menopause.

[33]  N. Biglia,et al.  Non-hormonal treatment of hot flushes in breast cancer survivors: gabapentin vs. vitamin E , 2009, Climacteric : the journal of the International Menopause Society.

[34]  Y. Taketani,et al.  Low-dose estradiol for climacteric symptoms in Japanese women: a randomized, controlled trial , 2009, Climacteric : the journal of the International Menopause Society.

[35]  R. Gut,et al.  Effective Treatment of Vaginal Atrophy With an Ultra–Low-Dose Estradiol Vaginal Tablet , 2008, Obstetrics and gynecology.

[36]  K. Hartmann,et al.  Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women , 2008, Menopause.

[37]  Nananda F. Col,et al.  Revisiting the Duration of Vasomotor Symptoms of Menopause: A Meta-Analysis , 2008, Journal of General Internal Medicine.

[38]  K. Slavin,et al.  Effects of stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study. , 2008, The Lancet. Oncology.

[39]  Wendy Shelly,et al.  Selective Estrogen Receptor Modulators: An Update on Recent Clinical Findings , 2008, Obstetrical & gynecological survey.

[40]  R. Gut,et al.  Efficacy of Low-Dose Estradiol Vaginal Tablets in the Treatment of Atrophic Vaginitis: A Randomized Controlled Trial , 2008, Obstetrics and gynecology.

[41]  P. Lam,et al.  A randomized, double-blind, placebo-controlled study of the effect of a Chinese herbal medicine preparation (Dang Gui Buxue Tang) on menopausal symptoms in Hong Kong Chinese women , 2008, Climacteric : the journal of the International Menopause Society.

[42]  Julie Brown,et al.  Phytoestrogens for vasomotor menopausal symptoms. , 2007, The Cochrane database of systematic reviews.

[43]  F. Verheugt,et al.  Estrogen therapy and coronary-artery calcification. , 2007, The New England journal of medicine.

[44]  K. Matthews,et al.  Adiposity and reporting of vasomotor symptoms among midlife women: the study of women's health across the nation. , 2007, American journal of epidemiology.

[45]  A. LaCroix,et al.  Vaginal, endometrial, and reproductive hormone findings: randomized, placebo-controlled trial of black cohosh, multibotanical herbs, and dietary soy for vasomotor symptoms: the Herbal Alternatives for Menopause (HALT) Study , 2007, Menopause.

[46]  J. Tice,et al.  Ineffectiveness of Sertraline for Treatment of Menopausal Hot Flushes: A Randomized Controlled Trial , 2007, Obstetrics and gynecology.

[47]  F. Clavel-Chapelon,et al.  Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study , 2007, Breast Cancer Research and Treatment.

[48]  S. Crawford.  The roles of biologic and nonbiologic factors in cultural differences in vasomotor symptoms measured by surveys , 2007, Menopause.

[49]  E. Tarım,et al.  How best is to discontinue postmenopausal hormone therapy: immediate or tapered? , 2007, Maturitas.

[50]  R. Gut,et al.  Ultra-low-dose estradiol and norethisterone acetate: effective menopausal symptom relief , 2007, Climacteric : the journal of the International Menopause Society.

[51]  Katherine Newton,et al.  Treatment of Vasomotor Symptoms of Menopause with Black Cohosh, Multibotanicals, Soy, Hormone Therapy, or Placebo , 2006, Annals of Internal Medicine.

[52]  K. Matthews,et al.  Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: study of women's health across the nation. , 2006, American journal of public health.

[53]  P. Novotny,et al.  Phase III double-blind, randomized, placebo-controlled crossover trial of black cohosh in the management of hot flashes: NCCTG Trial N01CC1. , 2006, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[54]  Rongwei Fu,et al.  Management of Miscarriage: Expectant, Medical, or Surgical? Results of Randomised Controlled Trial (Miscarriage Treatment [MIST] Trial) , 2006, Annals of internal medicine.

[55]  H. Depypere,et al.  A first prospective, randomized, double-blind, placebo-controlled study on the use of a standardized hop extract to alleviate menopausal discomforts. , 2006, Maturitas.

[56]  E. Vittinghoff,et al.  Effects of ultralow-dose transdermal estradiol on postmenopausal symptoms in women aged 60 to 80 years , 2006, Menopause.

[57]  E. Gold,et al.  Lifestyle factors: are they related to vasomotor symptoms and do they modify the effectiveness or side effects of hormone therapy? , 2005, The American journal of medicine.

[58]  J. Manson,et al.  Symptom experience after discontinuing use of estrogen plus progestin. , 2005, JAMA.

[59]  C. Castelo-Branco,et al.  Management of post-menopausal vaginal atrophy and atrophic vaginitis. , 2005, Maturitas.

[60]  M. Seif,et al.  Testosterone for peri- and postmenopausal women. , 2005, The Cochrane database of systematic reviews.

[61]  M. Birkhäuser,et al.  Cimicifuga racemosa dried ethanolic extract in menopausal disorders: a double-blind placebo-controlled clinical trial. , 2005, Maturitas.

[62]  J. Warnock,et al.  Combined esterified estrogens and methyltestosterone versus esterified estrogens alone in the treatment of loss of sexual interest in surgically menopausal women , 2005, Menopause.

[63]  S. Davis,et al.  Intranasal versus transdermal matrix oestrogen replacement in Australasian women. , 2005, Maturitas.

[64]  Hui Lin,et al.  The role of anxiety and hormonal changes in menopausal hot flashes , 2005, Menopause.

[65]  K. Maki,et al.  A Multicenter, Open-Label Study to Evaluate Satisfaction and Menopausal Quality of Life in Women Using Transdermal Estradiol/Norethindrone Acetate Therapy for the Management of Menopausal Signs and Symptoms , 2005, Gynecologic and Obstetric Investigation.

[66]  K. Matthews,et al.  Influence of hormone therapy on the cardiovascular responses to stress of postmenopausal women , 2005, Biological Psychology.

[67]  Susan R. Johnson,et al.  Uterine and Vaginal Effects of Unopposed Ultralow-Dose Transdermal Estradiol , 2005, Obstetrics and gynecology.

[68]  F. Facchinetti,et al.  Efficacy of Cimicifuga racemosa on climacteric complaints: A randomized study versus low-dose transdermal estradiol , 2005, Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology.

[69]  A. Maclennan,et al.  Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. , 2004, The Cochrane database of systematic reviews.

[70]  R. Rebar,et al.  A short study in the treatment of hot flashes with buccal administration of 17-beta estradiol. , 2004, Maturitas.

[71]  K. Matthews,et al.  The relationship of longitudinal change in reproductive hormones and vasomotor symptoms during the menopausal transition. , 2004, The Journal of clinical endocrinology and metabolism.

[72]  J. Manson,et al.  Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial , 2004 .

[73]  A. Tosteson,et al.  Predictors of Difficulty When Discontinuing Postmenopausal Hormone Therapy , 2003, Obstetrics and gynecology.

[74]  L. Speroff.  Efficacy and tolerability of a novel estradiol vaginal ring for relief of menopausal symptoms. , 2003, Obstetrics and gynecology.

[75]  K. Kieburtz,et al.  Gabapentin's Effects on Hot Flashes in Postmenopausal Women: A Randomized Controlled Trial , 2003, Obstetrics and gynecology.

[76]  F. al-Azzawi,et al.  Comparison of a novel vaginal ring delivering estradiol acetate versus oral estradiol for relief of vasomotor menopausal symptoms , 2003, Climacteric : the journal of the International Menopause Society.

[77]  E. Ernst,et al.  Randomised controlled trial of reflexology for menopausal symptoms , 2002, BJOG : an international journal of obstetrics and gynaecology.

[78]  R R Freedman,et al.  Physiology of hot flashes , 2001, American journal of human biology : the official journal of the Human Biology Council.

[79]  G. Bachmann,et al.  Relief of vasomotor symptoms and vaginal atrophy with lower doses of conjugated equine estrogens and medroxyprogesterone acetate. , 2001, Fertility and sterility.

[80]  S. Crawford,et al.  Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups. , 2001, Social science & medicine.

[81]  J. Grisso,et al.  Symptom reports from a cohort of African American and white women in the late reproductive years , 2001, Menopause.

[82]  J. Kelsey,et al.  Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age. , 2000, American journal of epidemiology.

[83]  H. Burger,et al.  A Prospective Population‐Based Study of Menopausal Symptoms , 2000, Obstetrics and gynecology.

[84]  Susan R. Johnson,et al.  Symptom Relief and Side Effects of Postmenopausal Hormones: Results From the Postmenopausal Estrogen/Progestin Interventions Trial , 1998, Obstetrics and gynecology.

[85]  P. Novotny,et al.  Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. , 1998, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[86]  B. Ettinger,et al.  Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. , 1997, Fertility and sterility.

[87]  M. Bygdeman,et al.  Replens versus dienoestrol cream in the symptomatic treatment of vaginal atrophy in postmenopausal women. , 1996, Maturitas.

[88]  A. Green,et al.  Menopausal symptoms in Australian women , 1993, The Medical journal of Australia.

[89]  A. Voda,et al.  The prevalence of hot flash and associated variables among perimenopausal women. , 1985, Research in nursing & health.

[90]  P. Lomax,et al.  Association of Waking Episodes with Menopausal Hot Flushes , 1981, JAMA.

[91]  N. Magrini,et al.  Short and long term effects of tibolone in postmenopausal women. , 2012, The Cochrane database of systematic reviews.

[92]  Management of Gynecologic Issues in Women With Breast Cancer , 2012 .

[93]  C. Farquhar,et al.  Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. , 2009, The Cochrane database of systematic reviews.

[94]  J. Simon.  Vulvovaginal atrophy: new and upcoming approaches. , 2009, Menopause.

[95]  N. Mutrie,et al.  Exercise for vasomotor menopausal symptoms. , 2007, The Cochrane database of systematic reviews.

[96]  P. Loehrer.  Phase III Comparison of Depomedroxyprogesterone Acetate to Venlafaxine for Managing Hot Flashes: North Central Cancer Treatment Group Trial N99C7 , 2007 .

[97]  D. Grady.  Clinical practice. Management of menopausal symptoms. , 2006, The New England journal of medicine.

[98]  O. Ylikorkala,et al.  Lack of effect of isoflavonoids on the vagina and endometrium in postmenopausal women. , 2005, Fertility and sterility.

[99]  G. Bachmann,et al.  The impact of hormones on menopausal sexuality: a literature review. , 2004, Menopause.

[100]  S. Cummings,et al.  Tibolone for postmenopausal women: systematic review of randomized trials. , 2002, The Journal of clinical endocrinology and metabolism.

[101]  W. Steinberg,et al.  17&bgr;‐Estradiol Vaginal Tablet Versus Conjugated Equine Estrogen Vaginal Cream to Relieve Menopausal Atrophic Vaginitis , 2000 .

[102]  I. Wiklund,et al.  Effects of a standardized ginseng extract on quality of life and physiological parameters in symptomatic postmenopausal women: a double-blind, placebo-controlled trial. Swedish Alternative Medicine Group. , 1999, International journal of clinical pharmacology research.

[103]  D. Brambilla,et al.  The normal menopause transition , 1992, American journal of human biology : the official journal of the Human Biology Council.

[104]  F Kronenberg,et al.  Hot flashes: epidemiology and physiology. , 1990, Annals of the New York Academy of Sciences.