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The marked decrease in estrogen levels in menopausal women can cause bothersome symptoms that affect daily life. More than 75% of women experience menopausal symptoms, which can include vaginal dryness, itching, discharge, dyspareunia, mood changes, hot flushes, and night sweats. Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms. Benefits include decreased risk of osteoporotic fractures and vaginal atrophy, improved glycemic control, and decreased vasomotor symptoms. However, recent research on risks associated with MHT has shown increased risk of venous thromboembolism and breast cancer. MHT typically is an option for patients younger than 60 years or within 10 years of menopause onset with bothersome vasomotor symptoms. The decision to start MHT should be made on an individual basis after a thorough evaluation and counseling. Oral, intramuscular, transdermal, and intravaginal formulations are available. The goal of therapy is use of the lowest dose for the shortest time that effectively manages symptoms. The patient and physician should regularly assess the risks and benefits associated with MHT and ensure that the benefits of its use continue to outweigh the risks.

Case 2. KF is a 52-year-old patient with a history of major depressive disorder and obesity. She has a family history of breast cancer in a paternal aunt. She went through menopause 3 years ago and is frustrated that her symptoms have persisted. She continues to experience hot flushes, episodic night sweats, and vaginal dryness. KF mentions that when her mother completed menopause, she took estrogen therapy. KF says she has heard she may be a candidate for therapy. She says her symptoms are disrupting her life, and she wants to find appropriate and safe ways to return to a more comfortable baseline.

Pathophysiology of Menopausal Symptoms

Patients born with ovaries are born with a finite number of ovarian follicles. These follicles decrease in number over time primarily through ovulation, and estrogen levels fall when the main producers of estrogen, the granulosa cells in ovarian follicles, decrease. The reduction in estrogen causes vasomotor symptoms, such as hot flushes and sweats, and joint and muscle pain, low mood, and decreased sexual desire.28,29 Patients also may experience vaginal dryness, dyspareunia, pruritis, and abnormal discharge due to vaginal mucosal atrophy.

More than 75% of women experience menopausal symptoms, most commonly vasomotor symptoms, with 25% of women reporting severe symptoms.30 Many patients experience symptoms with an average duration of 7 years, but one-third have symptoms beyond this time period.29

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