Menopause: Don’t sweat it: Part 2 – Therapies

Please note: This is the second article in a series on menopause. See Part 1 for details on identifying the symptoms of menopause.

Authors

Kerstin Gustafson MD FRCSC (biography and disclosures) and Colleen Dy MD FRCS(C) NCMP (biography and disclosures)

Dr. Kerstin Gustafson’s disclosures: Received payments as honoraria for speaking on various medical topics, both from for-profit organizations and from non-profits such as the SOGC. Served on regional advisory boards for Amgen, Lilly, Pfizer, Bayer, Sanofi, and Novartis. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with clinical trial data and published practice guidelines.

Dr. Colleen Dy’s disclosures: I received payments as honoraria for speaking on various medical topics from Pfizer, Merck, Apotex, Knight, and BioSyentI. I served on regional advisory boards for Pfizer, Apotex, and Astellas. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with clinical trial data and published practice guidelines.

What care gaps or frequently asked questions we have noticed

Menopause is expected to cause symptoms in about 80% of patients. These can vary from mild to very severe and debilitating. The most common are collectively termed vasomotor symptoms (VMS), including hot flushes and night sweats, but over 30 distinct symptoms have been identified, including those affecting multiple domains of health.¹

We have identified the main symptom groups in a previous TCMP article titled Menopause: Don’t sweat it: Part 1.² Because of the prevalence and wide range of symptomatology around the time of menopause, women frequently seek advice from their primary care provider.³ Patients often ask about the available treatment options and the pros and cons of each. With expanding Pharmacare coverage, menopausal therapies will be more accessible in the near future.⁴ We will use the term ‘women’ to describe people experiencing menopause, while understanding that some people may identify differently.

In addition to answering the sometimes surprisingly difficult question about whether the patient is menopausal, it is also complicated to decide which treatments the patient would be eligible for, as well as what the available options are. We have recommended resources including a treatment algorithm, the MQ6, in our previous article.^5,6

Recently, menopause has been frequently discussed on social media. There is a great deal of both misinformation and disinformation that may lead your patient to request treatment for non-standard indications. We should be aware that, based on existing science and clinical evidence, estrogen-containing hormone therapy is not recommended for primary prevention of: cardiovascular disease or dementia in women who experience menopause at the average age; management of musculoskeletal conditions outside of osteoporosis risk reduction (e.g., arthritis, joint pain, etc); prevention of aging; and management of other primarily age-related changes such as hair loss, skin changes and weight gain.⁷

Data that answers these questions

Deciding whether the patient is menopausal

The question of whether a patient is in menopause can be tricky. Menopause marks the permanent cessation of fertility and is retrospectively defined after one year without a period.⁸ Patients who have had a hysterectomy or use hormonal contraception, for example, may not be certain about when or whether the final menstrual period (FMP) has occurred. Menopause is not defined by any particular follicle-stimulating hormone (FSH) level, and Choosing Wisely recommends against using FSH to diagnose menopause in women over the age of 45.⁹ The frequency and severity of menopausal symptoms do not correlate to the levels of either FSH or serum estradiol.⁹ If patients are using hormonal contraception, it can be assumed that they no longer require contraception at the age of 55.¹⁰

Patients do not need to be in menopause to be offered treatment, including hormone therapy, for their menopausal symptoms. However, if under the age of 45, including FSH and tests for other possible causes of missing periods or menopausal symptoms should be carried out.¹¹ Symptomatic patients at any age should be offered a complete blood count (CBC), ferritin and thyroid-stimulating hormone (TSH), to rule out secondary causes. Patients considering hormone therapy should have a baseline mammogram and lipid profile for risk stratification.

Menopausal symptoms can vary from person to person, and treatment should be focused on the most bothersome symptoms. Patients can access a symptom tracker on the Menopause Foundation of Canada website.¹²

Hormonal options

Menopausal hormone therapy (MHT) currently remains the most effective treatment for VMS, reducing hot flushes by up to 75%.¹³ For women who have bothersome menopausal symptoms and no contraindications, it should be offered as first-line therapy.¹³ MHT is safest when prescribed within 10 years of menopause OR before the age of 60.¹³ Patients only need to meet one of those criteria. For example, a woman who has menopause at the age of 57 can safely initiate MHT until the age of 67. There is no defined age or duration of therapy at which discontinuation of hormone therapy is required.¹³

Systemic estrogen alone can be used for patients without a uterus. This is distinct from local vaginal estrogen which is several hundred times lower in dose and generally considered safe in nearly all women.¹⁴ For a short discussion around vaginal estrogen and genitourinary syndrome of menopause (GSM), see our 2023 TCMP article, Genitourinary syndrome of menopause (GSM) — a refresher.¹⁵ For women who have a uterus, a progestin or progestin alternative should be used to prevent endometrial cancer.¹⁶ In women who are perimenopausal, still having menstrual bleeding, MHT can be preferentially used cyclically to reduce unscheduled bleeding,⁵ or a 52mg Levonorgestrel (LNG) IUD can be used to minimize heavy bleeding for up to five years.¹⁷ There is some evidence for effectiveness of progestins alone for VMS treatment.¹⁸ Alternatively, if there are no contraindications, a combined hormonal contraceptive can also be used for hormone therapy, regulation of menstrual cycles and to provide contraceptive and non contraceptive benefits.¹⁹

There are several different preparations of hormone therapy available in Canada, which are too numerous to fully detail in this review. A table of available preparations is available on the MQ6 website.⁵ In June 2025, the BC Government Provincial Academic Detailing service (PAD) released a helpful graphic describing available medications, including costs.²⁰ There is also a thorough 2023 review article in the CMAJ, outlining a strategy for prescribing MHT.¹¹ Hormone therapies fall into a few broad categories that we can summarize individually (see Table 1).

Custom compounds

Patients may request “bioidentical” or “custom-compounded” hormone preparations. The term “bioidentical” is a marketing term implying that the compound is natural and that pharmaceuticals are synthetic. “Custom compounding” is marketed to suggest that the dose has been individually formulated, often based on saliva or blood testing. These tests are unproven and are not recommended by any menopause society because of the absence of standardized reference ranges and the unreliability of the tests themselves.¹³ Patients have often been told that these customized preparations are safer than pharmaceuticals; however, the hormones used in both are all synthesized in the same pharmaceutical labs, so they present equivalent dose-related risks. Additionally, compounded bioidentical hormone therapy presents safety concerns related to lack of government regulation and monitoring; risks of overdosing and underdosing; presence of impurities and lack of sterility; absence of scientific efficacy and safety data; and lack of a label outlining risks.¹³

Table 1. Categories of hormonal therapies

Cost information for hormonal and non-hormonal therapies in BC is available through the BC Provincial Academic Detailing (PAD) service.

Non-hormonal options

For symptomatic patients who do not wish to use, or have contraindications, to hormone therapy, there are several non-hormonal options supported by The Menopause Society.²⁷ For help in deciding which patients should not use hormone therapy, please see the MQ6⁵ or the BC Government PAD guidance on green, yellow and red light patients.²⁰

The neurokinin B inhibitor, fezolinetant, was the first on-label non-hormonal treatment for VMS available in Canada²⁸, followed by elinzanetant.²⁹ Clonidine is not currently recommended due to a lack of supporting data, and the availability of safer, more effective options.³⁰ Oxybutynin has been shown to reduce moderate to severe VMS, although, in older adults, long-term use may be associated with cognitive decline.³⁰ The SSRI paroxetine should not be used in patients using tamoxifen. It inhibits the CYP2D6 enzyme, which is responsible for metabolizing tamoxifen into its active form, thereby reducing the levels of the active form of tamoxifen.³¹

Table 2. Medication class of non-hormonal therapies

Cost information for hormonal and non-hormonal therapies in BC is available through the BC Provincial Academic Detailing (PAD) service.

Non-prescription interventions, including cognitive behavioral therapy (CBT) and clinical hypnosis, have been shown to reduce VMS bother. Weight loss in overweight patients has been shown to reduce symptoms. Stellate ganglion block has shown promise.²⁷

Other interventions such as mindfulness-based interventions, cooling techniques, paced respiration, soy extracts, chiropractic interventions and herbal supplements are not recommended. Although cannabis is frequently used by midlife women in Canada to treat several symptoms associated with menopause, including anxiety, poor sleep and joint pain,³² it is not recommended due to a lack of evidence for effectiveness. However, more research into this is needed.

What we recommend (practice tip)

Menopause will affect all women who reach midlife. As care providers, we should be ready to respond to our patients’ midlife concerns with accurate and evidence-based information. We have listed many commonly prescribed preparations for managing VMS in menopause. Genitourinary syndrome of menopause (GSM) treatment has previously been discussed in our TCMP article, Genitourinary syndrome of menopause (GSM) — a refresher.¹⁵

Resources

Providers may be uncertain about how to begin prescribing menopause treatments if they have had limited training or experience with this subject. For guidance on how to prescribe we recommend the following resources:

• MQ6 Interactive Treatment Algorithm
• The Canadian Menopause Society Pocket Guide
• A pragmatic approach to the management of menopause – CMAJ
• Managing Menopause: VMS – BCMJ
• Menopause Hormone Therapy: 2023 Update – Canadian Primary Care Today
• Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle – Journal of Obstetrics and Gynaecology Canada
• Government of BC PAD Guideline on Menopausal Hormone Therapy

Other resources:

• Menopause Foundation of Canada: Symptom Tracker
• This Changed My Practice article: Genitourinary syndrome of menopause (GSM) — a refresher
• This Changed My Practice article: Menopause: Don’t sweat it: Part 1 – Symptoms

References

1. The Menopause Society. Symptoms. Published October 2022. Accessed October 4, 2024. (View)
2. Gustafson K, Dy C. Menopause: don’t sweat it: part 1. This Changed My Practice. February 26, 2025. Accessed October 4, 2024. (View)
3. Menopause Foundation of Canada. The Silence and the Stigma: Menopause in Canada. October 2022. Accessed May 5, 2024. (View PDF)
4. Joannou A. B.C. signs pharmacare deal with Ottawa covering hormone therapy, diabetes drugs. Global News. September 12, 2024. Accessed October 4, 2024. (View)
5. Goldstein S. MQ6 interactive treatment algorithm. MQ6 Menopause Management Tools. Published 2017. Accessed September 28, 2024. (View)
6. Goldstein S. An efficient tool for the primary care management of menopause. Can Fam Physician. 2017;63(4):295-298. Accessed September 16, 2025. (View)
7. The Menopause Society. Statement on hormone therapy misinformation. Published September 2024. Accessed October 4, 2024. (View PDF)
8. Soules, M. R., Sherman, S., Parrott, E., Rebar, R., Santoro, N., Utian, W., & Woods, N. (2001). Executive summary: Stages of Reproductive Aging Workshop (STRAW). Fertility and sterility, 76(5), 874–878. doi.org/10.1016/S0015-0282(01)02909-0 (View with UBC)
9. Society of Obstetricians and Gynaecologists of Canada. Obstetrics and gynaecology recommendations: Twelve tests and treatments to question. Choosing Wisely Canada. Updated August 2021. Accessed October 4, 2024. (View)
10. Allen, R. H., Cwiak, C. A., & Kaunitz, A. M. (2013). Contraception in women over 40 years of age. CMAJ 185(7), 565–573. doi.org/10.1503/cmaj.121280 (View)
11. Lega IC, Fine A, Antoniades ML, Jacobson M. A pragmatic approach to the management of menopause. CMAJ. 2023;195(19):E677-E672. doi:10.1503/cmaj.221438 (View)
12. Menopause Foundation of Canada. Menopause symptoms. Menopause Foundation of Canada. Published 2024. Accessed September 12, 2025. (View)
13. The 2022 Hormone Therapy Position Statement of The North American Menopause Society Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028 (View with UBC)
14. McVicker L, Labeit AM, Coupland CAC, et al. Vaginal Estrogen Therapy Use and Survival in Females With Breast Cancer. JAMA Oncol. 2024;10(1):103-108. doi:10.1001/jamaoncol.2023.4508 (View)
15. Gustafson K, Dy C. Genitourinary syndrome of menopause (GSM) — a refresher. This Changed My Practice. Published February 26, 2025. Accessed September 12, 2025. (View)
16. Pike MC, Peters RK, Cozen W, et al. Estrogen-progestin replacement therapy and endometrial cancer. J Natl Cancer Inst. 1997;89(15):1110-1116. doi:10.1093/jnci/89.15.1110 (View with UBC)
17. Varila E, Wahlström T, Rauramo I. A 5-year follow-up study on the use of a levonorgestrel intrauterine system in women receiving hormone replacement therapy. Fertil Steril. 2001;76(5):969-973. doi:10.1016/s0015-0282(01)02846-1 (View with UBC)
18. Dolitsky SN, Cordeiro Mitchell CN, Stadler SS, Segars JH. Efficacy of progestin-only treatment for the management of menopausal symptoms: a systematic review. Menopause. 2020;28(2):217-224. Published 2020 Nov 12. doi:10.1097/GME.0000000000001676 (View with UBC)
19. Kaunitz AM. Oral contraceptive use in perimenopause. Am J Obstet Gynecol. 2001;185(2 Suppl):S32-S37. doi:10.1067/mob.2001.116525 (View with UBC)
20. BC Provincial Academic Detailing (PAD) Service. Medications for menopause-associated vasomotor and genitourinary symptoms. Government of British Columbia. Published June 25, 2025. Accessed September 12, 2025. (View)
21. Canonico M, Oger E, Plu-Bureau G, et al. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. Circulation. 2007;115(7):840-845. doi:10.1161/CIRCULATIONAHA.106.642280 (View with UBC)
22. Black D. The safety of oral versus transdermal estrogen. Menopause. 2020;27(11):1328-1329. doi:10.1097/GME.0000000000001636 (View with UBC)
23. Shufelt CL, Manson JE. Menopausal Hormone Therapy and Cardiovascular Disease: The Role of Formulation, Dose, and Route of Delivery. J Clin Endocrinol Metab. 2021;106(5):1245-1254. doi:10.1210/clinem/dgab042 (View with UBC)
24. Formoso G, Perrone E, Maltoni S, et al. Short-term and long-term effects of tibolone in postmenopausal women. Cochrane Database Syst Rev. 2016;10(10):CD008536. Published 2016 Oct 12. doi:10.1002/14651858.CD008536.pub3 (View)
25. Lundström E, Christow A, Kersemaekers W, et al. Effects of tibolone and continuous combined hormone replacement therapy on mammographic breast density. Am J Obstet Gynecol. 2002;186(4):717-722. doi:10.1067/mob.2002.121896 (View with UBC)
26. Hoffman SR, Governor S, Daniels K, et al. Comparative safety of conjugated estrogens/bazedoxifene versus estrogen/progestin combination hormone therapy among women in the United States: a multidatabase cohort study. Menopause. 2023;30(8):824-830. doi:10.1097/GME.0000000000002217 (View)
27. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590. doi:10.1097/GME.0000000000002200 (View with UBC)
28. Morga A, Zimmermann L, Valluri U, Siddiqui E, McLeod L, Bender RH. Validation and Application of Thresholds to Define Meaningful Change in Vasomotor Symptoms Frequency: Analysis of Pooled SKYLIGHT 1 and 2 Data. Adv Ther. 2024;41(7):2845-2858. doi:10.1007/s12325-024-02849-2 (View)
29. Simon JA, Anderson RA, Ballantyne E, et al. Efficacy and safety of elinzanetant, a selective neurokinin-1,3 receptor antagonist for vasomotor symptoms: a dose-finding clinical trial (SWITCH-1). Menopause. 2023;30(3):239-246. doi:10.1097/GME.0000000000002138 (View)
30. Yuksel N, Evaniuk D, Huang L, et al. Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle. J Obstet Gynaecol Can. 2021;43(10):1188-1204.e1. doi:10.1016/j.jogc.2021.08.003 (View with UBC)
31. Stearns V, Johnson MD, Rae JM, et al. Active tamoxifen metabolite plasma concentrations after coadministration of tamoxifen and the selective serotonin reuptake inhibitor paroxetine. J Natl Cancer Inst. 2003;95(23):1758-1764. doi:10.1093/jnci/djg108 (View with UBC)
32. Babyn K, Ross S, Makowsky M, Kiang T, Yuksel N. Cannabis use for menopause in women aged 35 and over: a cross-sectional survey on usage patterns and perceptions in Alberta, Canada. BMJ Open. 2023;13(6):e069197. Published 2023 Jun 21. doi:10.1136/bmjopen-2022-069197 (View)

Vote

Please indicate how this article will change your practice:

Menopause: Don't sweat it: Part 2 – Therapies

• I disagree with this approach
• I will consider changing my practice, but need more information/time
• I will likely change my practice
• I will definitely change my practice
• I already do this

View Results

 Loading ...