ACOG Clinical Guidelines on Management of Menopausal Symptoms

The American College of Obstetricians and Gynecologists (ACOG) has provided recommendations for the treatment of vasomotor and vaginal symptoms related to menopause.

Vasomotor and vaginal symptoms are cardinal symptoms of menopause. Vasomotor symptoms can be particularly troubling to women and are the most commonly reported menopausal symptoms.

Menopausal Symptoms

There is an array of menopausal symptoms; however, vasomotor and vaginal symptoms are the most closely related to hormonal changes during the transition to menopause.

Treatment Options for Menopausal Symptoms

Systemic estrogen hormone therapy (HT), with or without progestin, is the most effective therapy for menopause-related vasomotor symptoms, with evidence from multiple studies supporting the effectiveness.

Estrogen is effective for relieving menopause-related atrophic vaginal symptoms, and all low-dose estrogen is approved by the FDA for this indication. For women with only vaginal symptoms, local therapy is recommended.

Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), clonidine (Catapres), and gabapentin (Neurontin) are effective nonhormonal medications for treating vasomotor symptoms, although paroxetine (Paxil) is the only nonhormonal medication approved by the U.S. Food and Drug Administration (FDA) for this indication.

Generic	Route	Approved for vasomotor symptoms	Approved for vaginal symptoms	Availability in Bangladesh
Estradiol	Transdermal	Yes	Yes	No
Conjugated estrogen/ bazedoxifene	Oral	Yes	No	Yes
Micronized Estradiol-	Oral	Yes	Yes	Yes
Micronized Estradiol	Topical	No	Yes	No
Estradiol-17β ring	Vaginal ring	No	Yes	No
Estradiol acetate	Vaginal ring	No	Yes	No
Ospemifene	Oral	No	Yes	Yes
Paroxetine	Oral	Yes	No	Yes
Conjugated estrogen	Oral	Yes	Yes	Yes
Conjugated estrogen	Topical	No	Yes	No
Estradiol	Vaginal tablet	No	Yes	No

Note: The American College of Obstetricians and Gynecologists guidelines mention other treatment options. Only those approved for this indication by the U.S. Food and Drug Administration are listed in this table.

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Key Points for Practice

Vasomotor symptoms are best managed with systemic HT, although alternatives such as SSRIs, SNRIs, and clonidine have been shown to be effective.
Vaginal symptoms are best treated with systemic or topical HT, but topical methods are preferable as they have fewer adverse effects.
Systemic HT should be given in the lowest dose and for the shortest period possible to decrease the risk of serious adverse events, such as thromboembolic disease and breast cancer.