Considerations in Managing Menopause-Related Symptoms

Armen Hareyan's picture

What are the important considerations in managing menopause-related symptoms in women with clinical characteristics or circumstances that may complicate decisionmaking?

Decisionmaking for women regarding treatment of menopausal symptoms requires balancing of potential benefits against potential risks. Women at high risk for serious medical outcomes with the use of estrogen include those with a history of breast cancer, those with an elevated risk of breast and/or ovarian cancer based on genetic factors and/or family history, and women who have, or are at high risk for, cardiovascular disease. Women with these risk factors may be particularly motivated to seek nonhormonal therapies to treat menopausal symptoms. A few small studies in breast cancer survivors suggest that some antidepressants (such as venlafaxine) can effectively treat vasomotor symptoms in women with breast cancer; other treatments, including clonidine and megestrol acetate, have also shown positive effects in a few studies. These treatments have their own adverse effects (such as low libido, nausea, dry mouth, or constipation) that need to be weighed against the potential benefits. The long-term safety of these agents in women with breast cancer has not been studied. Given the potential for estrogenic actions, the long-term safety of phytoestrogens for women in this category remains unknown. Vaginal estrogen preparations to treat vaginal dryness and pain with intercourse may also be an attractive option for these women. Such topical therapies are known to increase circulating estrogen levels, but by much smaller amounts than oral estrogen therapy. Because these topical therapies have not been studied in large numbers of women for long periods of time, actual levels of risk for long-term complications, such as breast cancer recurrence, while likely much lower than for oral therapy, are not fully known.

Women who have had their ovaries surgically removed (surgically induced menopause) often experience more severe symptomatology, including hot flashes and sexual dysfunction. Benefits and risks of estrogen therapy in these women are generally similar to those found in studies of other women who have had hysterectomies and are taking estrogen. Risks may be elevated, however, in women whose oophorectomies were performed specifically to treat or prevent cancer.


In women who have undergone an oophorectomy and a hysterectomy, some studies suggest that oral or transdermal testosterone improves sexual function and psychological well-being, though definitive studies are lacking. These studies did not demonstrate a benefit for testosterone for the treatment of hot flashes, vaginal dryness, sleep disturbances, or mood.


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