Many women experience menopausal symptoms during the menopausal transition and postmenopausal years.
Hot flashes, the most common symptom, typically resolve after several years, but for 15-20% of women, they interfere with quality of life. For these women,
estrogen therapy, the most effective treatment for
hot flashes, should be considered. The decision to use
hormone therapy involves balancing the potential benefits of
hormone therapy against its potential risks. Accumulating data suggest that initiation of
estrogen many years after menopause is associated with excess coronary risk, whereas initiation soon after menopause is not. Therefore, most now agree that short-term
estrogen therapy, using the lowest effective
estrogen dose, is a reasonable option for recently menopausal women with moderate to severe symptoms who are in good cardiovascular health. Short-term
therapy is considered to be not more than 4-5 yr because symptoms diminish after several years, whereas the risk of
breast cancer increases with longer duration of
hormone therapy. A minority of women may need long-term
therapy for severe, persistent vasomotor symptoms after stopping
hormone therapy. However, these women should first undergo trials of nonhormonal options such as
gabapentin,
selective serotonin reuptake inhibitors, or
serotonin norepinephrine reuptake inhibitors, returning to
estrogen only if these alternatives are ineffective or cause significant side effects. Low-dose vaginal
estrogens are highly effective for genitourinary
atrophy symptoms, with minimal systemic absorption and endometrial effects.