Algorithm for Menopausal Symptom Management

Algorithm for Menopausal Symptom Management - Flowchart

«Flowchart»

Moderate-to-severe hot flashes and/or night sweats?
(and inadequate response to behavioral/lifestyle modifications)

Yes

End

Assess CVD risk and time since menopause onset

CVD Risk over 10 Years
(ACC/AHA Risk prediction score)

	Years Since Menopause Onset
	5	6 to 10	>10
Low (<5%)	HT OK	HT OK	Avoid HT
Moderate (5% to 10%)	HT OK (Consider transdermal)	HT OK (Consider transdermal)	Avoid HT
High (>10%)	Avoid HT	Avoid HT	Avoid HT

Assess CVD risk and time since menopause onset

CVD Risk over 10 Years
(ACC/AHA Risk prediction score)

	Years Since Menopause Onset
	5	6 to 10	>10
Low (<5%)	HT OK	HT OK	Avoid HT
Moderate (5% to 10%)	HT OK (Consider transdermal)	HT OK (Consider transdermal)	Avoid HT
High (>10%)	Avoid HT	Avoid HT	Avoid HT

Assess CVD risk and time since menopause onset

CVD Risk over 10 Years
(ACC/AHA Risk prediction score)

	Years Since Menopause Onset
	5	6 to 10	>10
Low (<5%)	HT OK	HT OK	Avoid HT
Moderate (5% to 10%)	HT OK (Consider transdermal)	HT OK (Consider transdermal)	Avoid HT
High (>10%)	Avoid HT	Avoid HT	Avoid HT

Years Since Menopause Onset Years Since Menopause Onset 56 to 10>10 5 6 to 10 >10 Low (<5%)HT OKHT OKAvoid HT Low (<5%) HT OK HT OK Avoid HT Moderate (5% to 10%)HT OK
(Consider transdermal)HT OK
(Consider transdermal)Avoid HT Moderate (5% to 10%) HT OK
(Consider transdermal)
HT OK
(Consider transdermal)
Avoid HT High (>10%)Avoid HTAvoid HTAvoid HT High (>10%) Avoid HT Avoid HT Avoid HT

Interested in HT and free of contraindications?

Yes

Prior Hysterectomy?
Yes = estrogen alone
No = estrogen + progestogen
(CEE/bazedoxifene also may be an option)

DECISION ABOUT DURATION OF USE: continued moderate-to-severe symptoms; pt preference; weigh baseline risks of breast cancer, CVD, and osteoporosis.

Consider low-dose paroxetine or other well-studied SSRIs/SNRIs

Consider gabapentin, pregabalin, clonidine

Free of contraindications to SSRIs/SNRIs?

Yes

Adjust dose or consider gabapentin, pregabalin, clonidine

Continue

Adequate control of hot flashes?

Yes

Avoid HT

GSM symptoms such as vaginal dryness or pain with intercourse/sexual activity?

Yes

Vaginal lubricants and/or moisturizers

Consider low-dose vaginal estrogen. Ospemifene or prasterone also may be an option

Free of contraindications?

Yes

ACC, American College of Cardiology; AHA, American Heart Association; CEE, conjugated equine estrogens; CVD, cardiovascular disease; GSM, genitourinary syndrome of menopause; HT, hormone therapy; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors.