Introduction
This table summarises the main therapeutic strategies for menopausal symptoms, including hormonal and non-hormonal approaches for hot flushes and genitourinary syndrome.
Systemic hormone therapy for hot flushes
Hormone therapy is the most effective option for moderate to severe hot flushes in women during the menopausal transition or up to 10 years after menopause. In women with a uterus, oestrogen is used in combination with a progestogen, orally or transdermally, adjusting treatment according to response and tolerability. In hysterectomised women, oestrogen-only therapy is used. Contraindications include hormone-dependent breast cancer, previous venous or arterial thromboembolism, active coronary disease, stroke, unexplained genital bleeding, severe liver disease and pregnancy. The main risks include venous thromboembolism, stroke and, with prolonged use of certain regimens, increased risk of breast cancer. The transdermal route has a lower thrombotic risk than the oral route and may be preferred in women with vascular risk factors.
Tibolone
Tibolone is an alternative in women under 60 years of age or within 10 years of menopause, with no history of hormone-dependent breast cancer and no high vascular risk. It may improve hot flushes, mood, libido and bone mineral density. It is contraindicated in breast and endometrial cancer and in women aged 60 years or older because of the increased risk of stroke. Abnormal uterine bleeding should be assessed, and the therapeutic decision should be individualised.
Non-hormonal alternatives for hot flushes
Non-hormonal alternatives are intended for women with contraindications to hormones or who do not wish to use them. SSRIs and SNRIs, such as venlafaxine, desvenlafaxine, citalopram and escitalopram, reduce the intensity and frequency of hot flushes and are particularly useful when anxiety or depressive symptoms coexist. In women taking tamoxifen, paroxetine and fluoxetine should be avoided because of CYP2D6 inhibition, with venlafaxine or citalopram preferred. Common adverse effects include nausea, sleep disturbance, sexual dysfunction and sweating. Gabapentin is particularly useful for nocturnal hot flushes, starting with a low bedtime dose and gradual titration; it may cause drowsiness, dizziness and ataxia, requiring caution in older women and in renal impairment. Oxybutynin may be used in selected cases, with a risk of anticholinergic adverse effects such as dry mouth, constipation, urinary retention and possible cognitive impact. Fezolinetant, a neurokinin 3 receptor antagonist, reduces hot flushes without oestrogen exposure and requires liver monitoring; adverse effects include headache, gastrointestinal symptoms and elevated transaminases.
Genitourinary syndrome of menopause
Genitourinary syndrome includes vaginal dryness, pain during sexual intercourse and irritative urinary symptoms. In mild cases, regular use of vaginal moisturisers and lubricants is recommended. In moderate to severe cases, low-dose vaginal oestrogen is the most effective option and improves trophism, pH and lower urinary tract symptoms, with minimal systemic absorption and usually no need for a progestogen.
Other options for genitourinary symptoms
Other options include vaginal DHEA, useful for sexual pain and associated sexual symptoms, and oral ospemifene, a selective oestrogen receptor modulator that improves dyspareunia and signs of vaginal atrophy. Ospemifene is contraindicated in hormone-dependent breast cancer and requires assessment of thromboembolic risk. Systemic hormone therapy may treat both hot flushes and genitourinary syndrome in women without contraindications to hormones.
Oncological burden — breast cancer survivors
In survivors of hormone-dependent breast cancer, a stepwise approach is recommended, starting with non-hormonal measures and considering low-dose vaginal oestrogen only after treatment failure, through shared decision-making with oncology. The evidence suggests relative but limited safety, particularly in women taking aromatase inhibitors, justifying periodic monitoring and reassessment of benefit.
Final considerations and individualisation
Treatment choice should integrate symptom severity, cardiovascular and oncological risk, the woman’s preferences and impact on quality of life. The lowest effective dose for the shortest necessary duration should be favoured, with regular reassessment of benefit and potential risks.
