Treatment: Menopause

During perimenopause, low-dose combined oral contraceptives may be of benefit. The rational use of postmenopausal hormone therapy requires balancing the potential benefits and risks. Concerns include increased risks of endometrial cancer, breast cancer, thromboembolic disease, and gallbladder disease, as well as probably increased risks of stroke, cardiovascular events, and ovarian cancer. Benefits include a delay in postmenopausal bone loss and probably decreased risks of colorectal cancer and diabetes mellitus. Short-term therapy (<5 years) may be beneficial in controlling intolerable symptoms of menopause, as long as no contraindications exist. These include unexplained vaginal bleeding, active liver disease, venous thromboembolism, history of endometrial cancer (except stage I without deep invasion), breast cancer, preexisting cardiovascular disease, and diabetes. Hypertriglyceridemia (>400 mg/dL) and active gallbladder disease are relative contraindications. Alternative therapies for symptoms include venlafaxine, fluoxetine, paroxetine, gabapentin, clonidine, vitamin E, or soy-based products. Vaginal estradiol tablets may be used for genitourinary symptoms. Long-term therapy (≥5 years) should be undertaken only after careful consideration, particularly in light of alternative therapies for osteoporosis (bisphosphonates, raloxifene) and of the risks of venous thromboembolism and breast cancer. Estrogens should be given in the minimal effective doses (conjugated estrogen, 0.625 mg/d PO; micronized estradiol, 1.0 mg/d PO; or transdermal estradiol, 0.05-1.0 mg once or twice a week). Women with an intact uterus should be given estrogen in combination with a progestin (medroxyprogesterone either cyclically, 5-10 mg/d PO for days 15-25 each month, or continuously, 2.5 mg/d PO) to avoid the increased risk of endometrial carcinoma seen with unopposed estrogen use.