Supported by multiple clinical trials and systematic reviews
Menopause Symptoms
Menopause represents a natural transition marked by declining ovarian follicular activity, fluctuating then falling estradiol and inhibin, and compensatory rises in FSH/LH. Clinically it spans perimenopause (irregular cycles with vasomotor, sleep, and mood changes) to postmenopause (12 months of amenorrhea). Symptoms cluster into vasomotor symptoms (VMS: hot flashes/night sweats), genitourinary syndrome of menopause (GSM: vaginal dryness, dyspareunia, urinary symptoms), mood and cognitive complaints, sleep disturbance, and weight/body composition changes. Long-term health considerations include accelerated bone loss and shifts in cardiometabolic risk. Western medicine defines staging (e.g., STRAW+10), assesses symptom burden and risks, and individualizes therapy. Hormone therapy (HT) remains the most effective treatment for VMS and GSM and can help prevent bone loss. The contemporary interpretation of the Women’s Health Initiative (WHI) and subsequent analyses support the “timing hypothesis”: for most healthy women younger than 60 or within 10 years of menopause onset, benefits of appropriately selected HT generally outweigh risks, particularly with transdermal estradiol and micronized progesterone. HT is not indicated for primary prevention of cardiovascular disease, and risk assessment (breast cancer risk, VTE history, stroke risk, migraine with aura, liver disease) guides choice. Nonhormonal options have advanced: the neurokinin-3 receptor antagonist fezolinetant directly targets thermoregulatory dysfunction and reduces VMS frequency/severity; selective SSRIs/SNRIs (e.g., low-dose paroxetine, venlafaxine, desvenlafaxine, escitalopram) and gabapentin also help, especially when sleep is affected. For GSM, local vaginal estrogen, vaginal DHEA (prasterone), or the SERM ospemifene provide effective, often low-systemic-exposure relief. Bone health requires lifestyle, calcium/vitamin D adequacy, and when indicated, pharmacotherapy (bisphosphonates, denosumab, SERMs,
This content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting, stopping, or changing any supplement or medication regimen.
Western Medicine
Diagnosis
Clinical diagnosis based on 12 months of spontaneous amenorrhea (typical age 45–55) or menopausal symptoms with perimenopausal cycle changes. FSH/estradiol testing is not routinely required in women >45 unless premature ovarian insufficiency is suspected or atypical features exist. Use STRAW+10 staging for perimenopause, review medications/conditions that mimic VMS, and assess GSM, mood/sleep, cognitive complaints, bone density/fracture risk (FRAX), and cardiovascular risk (ASCVD estimator).
Treatments
- Lifestyle: weight management, regular aerobic and resistance exercise, sleep hygiene, limit alcohol, avoid smoking, paced breathing/cooling strategies
- Systemic hormone therapy (HT): 17β-estradiol (transdermal/oral) ± progestogen for women with a uterus; or CEE/bazedoxifene (tissue-selective estrogen complex)
- Progestogen choices: oral micronized progesterone, LNG-IUD for endometrial protection and contraception in perimenopause
- Nonhormonal VMS therapies: fezolinetant (NK3 receptor antagonist), SSRIs/SNRIs (e.g., paroxetine 7.5 mg, venlafaxine, desvenlafaxine, escitalopram), gabapentin; consider oxybutynin or clonidine when others unsuitable
- GSM treatments: low-dose vaginal estrogen (cream, tablet, ring), vaginal DHEA (prasterone), oral ospemifene; regular vaginal moisturizers/lubricants
- Mood/sleep/cognition: CBT-I for insomnia, treat depression/anxiety, optimize sleep and physical activity; HT not used for cognitive protection
- Bone health: calcium/vitamin D adequacy, weight-bearing/resistance exercise, fall prevention; pharmacotherapy for osteoporosis when indicated (bisphosphonates, denosumab, SERMs, anabolic agents)
- Cardiovascular risk reassessment: manage lipids, blood pressure, glucose; prefer transdermal estradiol in higher VTE risk; avoid HT for primary CVD prevention
Medications
- 17β-estradiol (transdermal patch/gel/spray; oral)
- Micronized progesterone (oral) or levonorgestrel intrauterine system
- Conjugated estrogens with bazedoxifene (TSEC)
- Fezolinetant (NK3 receptor antagonist)
- SSRIs/SNRIs: paroxetine 7.5 mg, venlafaxine, desvenlafaxine, escitalopram
- Gabapentin (especially for nocturnal VMS)
- Low-dose vaginal estrogen (estradiol or conjugated estrogens)
- Vaginal DHEA (prasterone)
- Ospemifene (SERM)
- Osteoporosis agents: alendronate, risedronate, zoledronic acid, denosumab, raloxifene/bazedoxifene, teriparatide, abaloparatide, romosozumab
Limitations
HT requires individualized risk assessment; not recommended for women with estrogen-dependent malignancy, active liver disease, unexplained vaginal bleeding, history of thromboembolism or stroke (unless specialist-guided exceptions). Nonhormonal options are generally less potent than HT and may cause adverse effects (e.g., SSRI sexual side effects, gabapentin sedation). Long-term cardiovascular or fracture outcomes for newer agents like fezolinetant are still accruing. Cognitive complaints have multifactorial causes; robust disease-modifying therapies are lacking. Access and cost can limit care; disparities in symptom burden and treatment uptake persist.
Sources
- The North American Menopause Society (NAMS). 2022 Position Statement: The 2022 hormone therapy position statement of The North American Menopause Society.
- NAMS. 2023 Position Statement: Nonhormone therapy for vasomotor symptoms.
- NAMS. 2020 Position Statement: Genitourinary syndrome of menopause (GSM).
- Manson JE et al. JAMA 2013; results from the WHI hormone therapy trials (intervention and poststopping phases).
- Manson JE et al. JAMA 2017; long-term all-cause and cause-specific mortality after WHI hormone therapy.
- Schierbeck LL et al. BMJ 2012 (DOPS): Early postmenopausal HT and cardiovascular outcomes.
- Harman SM et al. Ann Intern Med 2014 (KEEPS): Effects of early initiation of HT on surrogate vascular outcomes.
- Lancet 2023: Phase 3 SKYLIGHT 1 & 2 trials of fezolinetant for vasomotor symptoms.
- ACOG Practice Bulletin/Committee Opinion on management of menopausal symptoms and GSM.
- Endocrine Society/NOF osteoporosis guidelines for postmenopausal bone health.
Eastern & Traditional Medicine
Traditional Chinese Medicine (TCM)
Menopause is often framed as kidney yin deficiency leading to empty heat, with possible liver qi stagnation and disharmony of heart-kidney. Treatment follows pattern differentiation to nourish kidney yin/essence, clear deficiency heat, soothe liver, and calm the spirit.
Techniques
- Pattern-based herbal formulas (e.g., Liu Wei Di Huang Wan; Zhi Bai Di Huang Wan for yin deficiency with heat; Er Xian Tang for deficiency heat)
- Dietary and lifestyle guidance (cooling foods, stress regulation)
- Qigong/breath practices to regulate heat and mood
Acupuncture
Acupuncture aims to regulate hypothalamic thermoregulation and autonomic balance, reduce sympathetic tone, and modulate endogenous opioids and neuropeptides implicated in hot flashes.
Techniques
- Body acupuncture 1–2 sessions/week for 6–12 weeks; common points include SP6, KI3, LR3, LI4, HT7, PC6, GV20 (individualized)
- Electroacupuncture in some protocols
- Adjunct auricular acupuncture
Chinese Herbal Medicine
Use of multi-herb formulas to replenish yin, clear heat, and stabilize mood/sleep during menopausal transition, tailored to pattern (e.g., yin deficiency, liver qi stagnation).
Techniques
- Formulas such as Liu Wei Di Huang Wan, Zhi Bai Di Huang Wan, Er Xian Tang; individualized modifications
- Decoctions, granules, or patent pills with monitoring for efficacy/safety
Ayurveda
Menopause may reflect decline of ojas with vata-pitta imbalance manifesting as heat, insomnia, mood lability, and dryness. Therapy emphasizes rasayana (rejuvenation), nervine tonics, and diet/lifestyle to balance doshas.
Techniques
- Herbal rasayanas: Shatavari (Asparagus racemosus) for vasomotor and urogenital dryness; Ashwagandha (Withania somnifera) for stress, sleep, and mood
- Abhyanga (warm oil self-massage), nasya (nasal oil), cooling diet, yoga/pranayama
Sources
- Cochrane Database Syst Rev 2016: Chinese herbal medicine for menopausal symptoms (heterogeneous evidence).
- Bensky & Gamble Materia Medica texts (traditional patterns and formulas).
- Cochrane Database Syst Rev 2013/2016 (Smith CA et al.): Acupuncture for vasomotor menopausal symptoms—modest reductions vs no treatment; variable vs sham.
- Menopause 2021 meta-analyses: clinically meaningful reductions in hot flash frequency/severity vs waitlist/usual care.
- Cochrane Database Syst Rev 2016: Chinese herbal medicine for menopausal symptoms—evidence mixed; methodological limitations; some trials suggest benefit for VMS and sleep.
- Small randomized trials and systematic reviews suggest Ashwagandha improves sleep/anxiety and Shatavari may benefit menopausal symptoms; overall evidence quality low-to-moderate with heterogeneity.
Integrative Perspective
Personalized menopause care can combine first-line, evidence-based Western options with supportive traditional modalities. Examples: (1) For healthy women within 10 years of menopause with moderate–severe vasomotor symptoms, consider low-dose transdermal estradiol plus micronized progesterone for symptom relief and bone protection; add acupuncture (6–8 weeks) to accelerate VMS control and improve sleep, and teach paced breathing or mindfulness for stress. (2) For women who prefer to avoid or cannot use systemic hormones, consider fezolinetant or an SSRI/SNRI for VMS; add acupuncture and sleep-focused CBT-I or yoga nidra for insomnia; trial dietary soy (2–3 servings/day) or standardized soy isoflavones if no contraindications, monitoring response over 8–12 weeks. (3) For GSM, prioritize local vaginal estrogen or DHEA with vaginal moisturizers; pelvic floor physical therapy and, if desired, vaginal laser only in research/selected contexts; TCM herbal support may target dryness but should be coordinated with clinicians. Safety distinctions: Phytoestrogens (e.g., soy isoflavones, red clover) are dietary or supplement compounds with weak estrogenic activity; dietary soy is generally safe, including for most breast cancer survivors per oncology guidelines, whereas concentrated supplements warrant shared decision-making. In contrast, compounded “bioidentical” hormones lack FDA oversight, have variable dosing/purity, and rely on unvalidated salivary testing; prefer FDA-approved bioidentical products (17β-estradiol, micronized progesterone) with established safety/quality. Regularly reassess symptom control and risks (breast, VTE, CVD, bone), taper or continue therapies based on goals and updated evidence.
Sources
- The North American Menopause Society (NAMS). 2022 Hormone Therapy Position Statement.
- NAMS. 2023 Nonhormone Therapy Position Statement for Vasomotor Symptoms.
- NAMS. 2020 Genitourinary Syndrome of Menopause Position Statement.
- Manson JE et al. JAMA 2013 and 2017 WHI follow-ups on outcomes and mortality.
- Schierbeck LL et al. BMJ 2012 (DOPS) early HT and CVD outcomes.
- Harman SM et al. Ann Intern Med 2014 (KEEPS) early HT vascular surrogates.
- Lancet 2023 SKYLIGHT 1 & 2 fezolinetant phase 3 trials.
- Cochrane Reviews: Acupuncture for vasomotor symptoms (2013/2016); Phytoestrogens for menopausal symptoms (2013, updates); Black cohosh for menopausal symptoms (2012); Chinese herbal medicine for menopause (2016).
- Hunter MS et al. randomized CBT trials for menopausal hot flushes and sleep (MENOS).
- National Osteoporosis Foundation/Endocrine Society guidelines for postmenopausal osteoporosis.
Health Disclaimer
This content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting, stopping, or changing any supplement or medication regimen.