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Hyperprolactinemia

Menopause

Information on how to access prescribing information and adverse event reporting can be found at the bottom of the page.

Treatment Options Overview for Menopause

There are many different options that patients can try to relieve menopause symptoms. This page will explore the following treatment options:

Systemic Therapies:

Prescription Hormone Replacement Therapy
hormone therapies that may be used to manage vasomotor symptoms and genitourinary symptoms including vulvovaginal atrophy

Prescription Nonhormone Therapy for Menopause
nonhormone therapies that may be used to manage vasomotor symptoms and vulvovaginal atrophy

Prescription Therapy for Prevention of Osteoporosis
therapies that may be used to prevent the development of osteoporosis and resulting fractures

Complementary and Alternative Medicine
nonpharmaceuticals such as red clover, black cohosh, and St. John's wort (lack of high quality data)

Supplements
calcium, vitamin D


Local Therapies

Prescription Vaginal Hormone Therapy
local therapy that may be used to manage genitourinary symptoms including vulvovaginal atrophy

Moisturizers and/or Lubricants
nonhormonal options that may help relieve symptoms associated with vulvovaginal atrophy ​​​​​​​

Discover more about each treatment option:​​​​​

 

Prescription Menopausal Hormone Therapy 

Systemic menopausal hormone therapy is considered to be the most effective treatment currently available for the management of vasomotor symptoms associated with menopause.1,2

The term hormone therapy includes a wide range of hormonal products and routes of administration, with potentially different benefits and risks (see table below).4

Please refer to the individual product SmPC before prescribing

Systemic Treatment Option* Appropriate Candidates Formulations Additional Information
Oestrogen alone
 
  • Without uterus
  • Those without contraindications
  • Oral
  • Transdermal
  • Conjugated oestrogens or 17b-estradiol
  • All types and formulations effective in reducing the frequency of hot flushes
  • Higher doses may control symptoms more rapidly but can yield a higher rate of side effects (eg, uterine bleeding, breast tenderness, headache)
Oestrogen + progestogen
  • With uterus
  • Those without contraindications
  • Oral
  • Transdermal
  • Addition of progestogen reduces risk of endometrial cancer associated with unopposed oestrogen therapy
  • Progestogen options: progesterone or synthetic progestins
Synthetic steroid (tibolone)
 
  • With or without uterus
  • Those without contraindications (ie, breast cancer history), an alternative to HRT
  • More than one year after menopause
  • Oral
  • Metabolised to molecules with affinity for oestrogen, progesterone, and androgen receptors
  • Effective for treating vasomotor symptoms and preventing vertebral and nonvertebral fractures
  • Should not be added to HRT 

HRT—hormone replacement therapy; SERM—selective estrogen receptor modulator. 
Table adapted from Barber4

The duration of treatment with hormonal agents should be reviewed periodically.4 There are no mandatory limitations on the duration of menopausal hormone therapy; the decision to continue therapy should be based on the specific goals of treatment and an objective estimation of ongoing individual benefits and risks.4

 

Prescription Nonhormone Therapy for Menopause

Prescription nonhormone therapies are available to alleviate select menopausal symptoms in women who are unable or unwilling to take local or systemic oestrogen therapy.4

For Vasomotor Symptoms
It is possible to treat vasomotor symptoms without use of hormones. This may be the sole option for women with contraindications to oestrogen or progesterone therapy (eg, women with a history of breast cancer).4

A variety of nonhormonal pharmacological agents have been shown to decrease the frequency and intensity of hot flushes in clinical trials; however, many of these agents may not be approved for this purpose.3 
 
The duration of treatment with nonhormonal agents should be reviewed periodically. Treatment initiation usually requires a step-wise increase in dose to minimize side effects. Similarly, treatment discontinuation usually involves a step-wise taper in dose over ≥ 2 weeks to avoid withdrawal symptoms.4
 
For Vulvovaginal Atrophy (VVA)
• Ospemifene is an oral selective oestrogen receptor modulator (SERM) approved for the systemic treatment of moderate to severe VVA associated with menopause in women who are not candidates for vaginal oestrogen therapy.6
• SERMs do not contain hormones, per se, and therefore are not strictly a form of menopausal hormone therapy.4,6
• Nevertheless, the biologic activity of SERMs is mediated through binding to oestrogen receptors, resulting in activation of some oestrogenic pathways (agonism) and blockade of others (antagonism).6

 

Prescription Therapy for Prevention of Osteoporosis




Therapy for osteoporosis and fracture prevention should be selected based on a balance of effectiveness, risk, and cost.4


 
Please refer to the individual product SmPC before prescribing
Systemic Treatment Option* Additional Information
Certain Hormone Replacement Therapies that are licensed for prevention of osteoporosis
  • Most appropriate therapy for fracture prevention in early menopause
    • First-line therapy for women 50-60 years old or within 10 years of menopause
    • Consider benefit-risk ratio and other available agents for patients 60-70 years old
    • Should not be initiated in patients ≥ 70 years
  • Decreases incidence of all fractures, even in women not at high risk of fracture
  • Only therapy proven to reduce fracture in patients with osteopenia
Bisphosphonates (zoledronic acid, alendronate)
  • Potent inhibitors of bone resorption proven to prevent vertebral and hip fractures
  • Association suggested between atypical femur shaft fractures and duration of use longer than 3-5 years (oversuppression of bone turnover)
  • Osteonecrosis of the jaw a rare complication; generally, only a risk at high doses (ie, doses higher than recommended for fracture prevention)
  • Optimal duration of bisphosphonate therapy and drug holiday are controversial; decisions should be based on an individualized assessment of risk and benefit
SERMs (raloxifene)
  • Proven to prevent vertebral and hip fractures
  • No effect on vasomotor symptoms associated with menopause
Strontium ranelate
  • Proven to reduce vertebral and nonvertebral fracture in patients with osteoporosis
  • Use generally limited to patients with severe osteoporosis and low risk of cardiovascular disease due to concerns regarding cardiovascular safety
Denosumab
  • Human monoclonal antibody directed against RANKL (receptor activator of nuclear factor kappa-B ligand) indicated for patients with osteoporosis at high risk for fracture
  • Proven to reduce vertebral, nonvertebral, and hip fractures
  • Administered SC every 6 months
BMD—bone mineral density; SERM—selective estrogen receptor modulator; SC--subcutaneously.

​​​​​Table adapted from Barber4


 

​​​​​Complementary and Alternative Medicine (Nonpharmaceuticals)

The role of complementary and alternative medicines in managing menopause symptoms remains controversial due to a lack of high-quality data.4

Studies and meta-analyses do not consistently support the efficacy of complementary/alternative or over-the-counter medications in reducing the severity or frequency of vasomotor symptoms.4
•  Soy and red clover (ie, isoflavone preparations) and traditional Chinese medicines have demonstrated variable efficacy compared to placebo in small randomized, controlled trials and small meta-analyses.4
• Black cohosh and St John’s wort have been associated with adverse effects and unfavorable drug-drug interactions with medications and should therefore be used with caution.4
 
Further data from larger randomized trials are needed to confirm the efficacy and safety of complementary and alternative medicines for management of menopause symptoms.4

 

Supplements

Calcium and/or vitamin D supplementation should be considered for patients not meeting daily dietary requirements and those being treated for high fracture risk.4

For postmenopausal women, the daily recommended dietary intake is:
• 1000-1500 mg of elemental calcium4
•  800-1000 IU of vitamin D1


 

Prescription Vaginal Hormone Therapy

Genitourinary symptoms respond well to oestrogen therapy (either local or systemic).4 Local low-dose oestrogen therapy is preferred for women whose symptoms are limited to the vagina.7
• Long-term vaginal treatment is often required since symptoms can recur upon cessation of therapy.4
• Low-dose vaginal oestrogen therapy produces minimal systemic absorption.9 Risks associated with systemic hormone therapy have not been identified with local low-potency/low-dose oestrogen therapy, although product labels may carry warnings based on studies using systemic therapies.4

Please refer to the individual product SmPC before prescribing 

Various local oestrogen preparations are available for treating genitourinary symptoms:4


​​​​​
 

Moisturisers and/or Lubricants

Vaginal moisturisers and lubricants can help alleviate symptoms associated with vaginal atrophy and dryness.4
• With regular use, these modalities may be very effective for some women.4
• These products can be used on their own or in combination with hormone therapy (systemic or topical).8


 
Moisturisers and/or lubricants, along with regular sexual activity, should be recommended for women wishing to avoid use of hormone therapy.4 These products may also benefit women taking hormone therapy who desire additional symptom relief.4,8
 


Estring (estradiol hemihydrate) prescribing information can be found here
Premarin (oestrogens, conjugated) prescribing information can be found here
Premique (medroxyprogesterone acetate oestrogens, conjugated) prescribing information can be found here

References
1. de Villiers TJ, Hall JE, Pinkerton JV, et al. Revised global consensus statement on menopausal hormone therapy. Climacteric. 2016;19(4):313-315.
2. Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011.
3. British Menopause Society. 2017. Treating hot flushes without hormones: What works, what doesn't. Available at: thebms.org.uk/2015/09/treating-hot-flushes-without-hormones-what-works-what-doesnt/
4. Baber RJ, Panay N, Fenton A; IMS Writing Group. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric. 2016;19(2):109-150.
5. Grady D, Barrett-Connor E. Menopause. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine, 25th ed. 2016. Philadelphia, PA: Saunders Elsevier; 2016:1623-1629.
6. Senshio Summary of Product Characteristics; December 2019. Available at: www.medicines.org.uk/emc/product/9417/smpc#gref (Accessed June 2022)
7. de Villiers TJ, Hall JE, Pinkerton JV, et al. Revised global consensus statement on menopausal hormone therapy. Climacteric. 2016;19(4):313-315.
8. Edwards D, Panay N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? Climacteric. 2016;19(2):151-161.
9. NHS Trust, University Hospitals Coventry and Warwickshire. 2020.Low Dose Vaginal Oestrogen Therapy Patient Information Version 2.1. 
PP-UNP-GBR-0581. June 2022

Diagnosing Menopause

​​​​​​​
Learn the fundamental strategies for diagnosing menopausal symptoms principles before you make a treatment decision

Learn more

Common Symptoms


Discover common symptoms of menopause with anatomy and physiology to help understand the condition and reassure patients

Learn more

Managing Menopause


​​​​​​​Learn recommendations to support patients with lifestyle, diet and exercise, core recommendations regarding hormone replacement therapy (HRT), appropriate candidates for HRT, benefit-risk profile of HRT and Bioidentical Hormone Therapy

Learn more

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PP-PFE-GBR-3863. November 2021

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