What Should You Do About Menopause Symptoms?
Talk to your doctor about treatment options based on your symptom severity and medical history. For moderate-to-severe hot flashes, menopausal hormone therapy (MHT) is the most effective treatment. For mild symptoms or women who cannot take hormones, non-hormonal options including SSRIs, CBT, and fezolinetant are effective alternatives.
The 2022 North American Menopause Society (NAMS) position statement provides the most current evidence-based guidance. For vasomotor symptoms, systemic hormone therapy (estrogen alone for women without a uterus, combined estrogen-progestin for women with a uterus) remains the gold standard, reducing hot flash frequency by 75-90% and severity significantly. For women within 10 years of menopause onset or under age 60, the benefits of MHT for symptom relief, bone protection, and potential cardiovascular benefit outweigh the small risks.
Non-hormonal prescription options have expanded significantly. The FDA approved fezolinetant (Veozah) in 2023 — a neurokinin 3 (NK3) receptor antagonist that targets the thermoregulatory center directly. Clinical trials showed fezolinetant reduced moderate-to-severe hot flashes by 60% at 12 weeks. SSRIs (paroxetine 7.5 mg, the only FDA-approved non-hormonal option before fezolinetant), SNRIs (venlafaxine), and gabapentin also reduce hot flashes by 40-60%. Cognitive behavioral therapy (CBT) specifically designed for menopause reduces hot flash bother by 50-70%.
The 2022 NAMS position statement provides evidence-based guidance on menopausal hormone therapy
What Are the Most Common Menopause Symptoms?
The most common symptoms include vasomotor symptoms (hot flashes and night sweats, 80% of women), sleep disturbances (40-60%), vaginal dryness and painful intercourse (50%), mood changes including irritability and anxiety (40%), cognitive changes ('brain fog'), joint pain, weight changes, and urinary symptoms. Symptoms vary greatly in severity and duration.
Vasomotor symptoms (VMS) — hot flashes and night sweats — are the hallmark of menopause and the primary reason women seek treatment. A hot flash is a sudden sensation of heat, usually starting in the chest or face, accompanied by flushing, sweating, and sometimes palpitations, lasting 1-5 minutes. The SWAN study found VMS lasted a median of 7.4 years, with significant variation. Night sweats disrupt sleep quality, contributing to daytime fatigue, irritability, and cognitive difficulties.
Genitourinary syndrome of menopause (GSM) — formerly called vaginal atrophy — affects approximately 50% of postmenopausal women and worsens progressively without treatment. Declining estrogen causes vaginal dryness, thinning, loss of elasticity, painful intercourse (dyspareunia), and urinary symptoms including frequency, urgency, and recurrent UTIs. Unlike hot flashes, GSM does not resolve over time. Low-dose vaginal estrogen is the most effective treatment and is safe for most women, including many breast cancer survivors.
What Is Menopausal Hormone Therapy and Who Should Consider It?
MHT uses estrogen (with progestogen if the uterus is intact) to replace declining ovarian hormones. It is recommended for women under 60 or within 10 years of menopause with bothersome vasomotor symptoms, and for women with premature or early menopause. MHT also prevents osteoporosis and may have cardiovascular benefits when started early.
The 'timing hypothesis' has reframed MHT safety. The original Women's Health Initiative (WHI) trial caused widespread MHT discontinuation by reporting increased breast cancer and cardiovascular events. However, re-analysis showed the increased risk applied primarily to women over 60 who started MHT more than 10 years after menopause. The WHI estrogen-alone arm (for women without a uterus) actually showed a non-significant reduction in breast cancer risk and significantly reduced hip fracture risk. For women starting MHT in the early menopause window, the benefit-risk profile is favorable.
Options include systemic estrogen (oral, transdermal patches, gels, sprays) combined with micronized progesterone or a progestin for endometrial protection in women with a uterus. Transdermal estrogen is preferred for women with cardiovascular risk factors or migraine, as it avoids first-pass hepatic metabolism and has a lower VTE risk compared to oral estrogen. Body-identical (micronized) progesterone appears to have a better safety profile for breast cancer risk compared to synthetic progestins like medroxyprogesterone acetate.
The WHI re-analysis showed increased risk applied primarily to women starting MHT more than 10 years after menopause
How Can You Manage Menopause Without Hormones?
Non-hormonal options include prescription medications (fezolinetant, low-dose paroxetine, venlafaxine, gabapentin), cognitive behavioral therapy (CBT), regular exercise, weight management, and lifestyle modifications. For vaginal symptoms, non-hormonal moisturizers and lubricants provide relief. These approaches can reduce hot flashes by 40-70%.
Fezolinetant (Veozah), approved by the FDA in May 2023, represents a new class of non-hormonal treatment specifically targeting the neurokinin B (NKB) signaling pathway that drives vasomotor symptoms. The SKYLIGHT trials demonstrated that fezolinetant 45 mg daily reduced moderate-to-severe VMS frequency by approximately 60% at 12 weeks with sustained effects at 52 weeks. Common side effects include abdominal pain, diarrhea, and insomnia. Liver function monitoring is required during treatment.
Cognitive behavioral therapy for menopause (CBT-Meno) is the best-studied non-pharmacological intervention. A randomized trial published in The Lancet found that group CBT reduced the perceived problem of hot flashes by 50-70%, with benefits maintained at 6 months. CBT works by changing thoughts and behaviors related to hot flashes rather than reducing their physiological frequency. Regular aerobic exercise, while not consistently shown to reduce hot flash frequency, significantly improves mood, sleep quality, cardiovascular health, and overall quality of life during menopause.
The SKYLIGHT trials demonstrated fezolinetant reduced moderate-to-severe VMS frequency by approximately 60%
