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Menopause - Management
How can I manage menopausal symptoms without HRT?

  • Offer lifestyle advice to control symptoms; if this is not effective, consider other treatments.
  • For vasomotor symptoms, consider:
    • A trial (2 weeks) of paroxetine (20 mg daily), fluoxetine (20 mg daily), citalopram (20 mg daily), or venlafaxine 37.5 mg twice a day.
      • Antidepressants are unlicensed for treating menopausal symptoms.
    • A trial (2–4 weeks) of clonidine (50 to 75 micrograms twice a day, licensed use).
    • Seek specialist advice if a progestogen such as norethisterone or megestrol (both unlicensed) are being considered.
  • For vaginal dryness, prescribe a vaginal lubricant or moisturizer, such as Replens MD®.
  • Manage psychological symptoms, such as mood disturbances, anxiety, and depression, on an individual basis. They may be addressed using self-help groups, psychotherapy, other forms of counselling, or antidepressants.
  • CKS does not recommend the use of complementary therapies (e.g. soy, red clover, black cohosh). If complementary or herbal products are being used, advise the woman that:
    • The efficacy of these products has not yet been established.
    • There is very little control over the quality of the products available, which may vary considerably.
    • Some of these treatments (ginseng, black cohosh, and red clover) have oestrogenic properties and should not be used in women with contraindications to oestrogen (e.g. breast cancer).
    • Long-term safety (e.g. effects on the breast and endometrium) have not been assessed.
    • Some treatments may have serious adverse effects (e.g. liver toxicity has been reported with black cohosh and kava):
      • Kava has been withdrawn from the UK market.
    • Dong quai extracts and some species of red clover contain coumarins, which make them unsuitable for women taking anticoagulants.
Basis for recommendation
  • These recommendations are based on published expert opinion from the Medicines and Healthcare products Regulatory Agency, formerly known as the Committee on Safety of Medicines [CSM, 2003; CSM, 2004; ICSI, 2006; RCOG, 2006; Rees and Purdie, 2006].
  • Progestogens:
    • There is evidence that norethisterone and megestrol are effective for treating hot flushes. However, doses which achieve vasomotor control may increase the risk of thromboembolism and may not be suitable for women at increased risk of thromboembolic disease (personal or family history, known thrombophilia) [BMS, 2006]. Long term safety data is lacking.
  • Antidepressants:
    • Limited evidence indicates that venlafaxine, fluoxetine, citalopram, and paroxetine are effective for treating hot flushes. They are not licensed for this use but may be considered in treating women who cannot, or do not want to take hormone replacement therapy.
    • When effective, antidepressants provide relief from hot flushes almost immediately. A 1-week trial is generally sufficient to determine whether an antidepressant is going to be effective [ICSI, 2006].
  • Clonidine:
    • Clonidine is licensed for the treatment of vasomotor symptoms. There is limited evidence of its efficacy. It may cause unacceptable adverse effects (e.g. dry mouth, sedation, depression, fluid retention) [Rees and Purdie, 2006; BNF 54, 2007].
    • Clonidine should be stopped if no benefit is noted after 2–4 weeks of treatment or if a woman experiences adverse effects, including dizziness, dry mouth, drowsiness, and constipation [SOGC, 2006].
  • Complementary therapies:
    • No convincing evidence indicates that complementary therapies are effective for managing menopausal symptoms, but prospective randomized controlled trials are required to confirm the efficacy and long-term safety of these therapies [RCOG, 2006].
  • Other treatments:
    • Gabapentin:
      • Limited evidence indicates that gabapentin is effective for reducing hot flushes; further work is being done to confirm this, and use of gabapentin is restricted to specialist centres [RCOG, 2006].
    • Beta-blockers:

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