Comparison of a novel vaginal ring delivering estradiol acetate versus oral estradiol for relief of vasomotor menopausal symptoms

Safety and acceptability of intravaginal rings releasing estradiol and progesterone

OBJECTIVE

This study aimed to evaluate the safety and acceptability of two fixed-dose 28-day vaginal ring formulations of 17β-estradiol (E2) and progesterone (P4) to treat vasomotor symptoms (VMS) and the genitourinary syndrome of menopause.

DESIGN

DARE HRT1-001 was the first-in-woman study of 28-day exposure to two 28-day intravaginal rings (IVRs) designed to release 80 µg/day E2 + 4 mg/day P4 (IVR1) or 160 µg/day E2 + 8 mg/day P4 (IVR2) compared with oral E2 1 mg/day + oral P4 100 mg/day. To assess safety, participants completed a daily diary to record treatment emergent adverse events (TEAEs). To determine acceptability, at the end of treatment IVR users completed a questionnaire assessing tolerability and usability.

RESULTS

Enrolled women (n = 34) were randomized to use IVR1 (n = 10), IVR2 (n = 12) or oral (n = 12). Thirty-one participants (IVR1 = 10, IVR2 = 10, oral = 11) completed the study. The TEAE profile of those in the IVR groups were similar to the referent oral regimen. TEAEs related to the study product were more common with IVR2 use. Endometrial biopsies were not performed unless endometrial thickness was >4 mm or for clinically significant postmenopausal bleeding. One IVR1 participant had an endometrial stripe increase from 4 mm at screening to 8 mm at the end of treatment. The biopsy indicated no evidence of plasma cells or endometritis and no evidence of atypia, hyperplasia or malignancy. Two other endometrial biopsies were performed for postmenopausal bleeding with similar findings. There were no clinically meaningful laboratory or vital sign abnormalities or trends identified in observed values or changes from baseline. Pelvic speculum examination identified no clinically significant abnormalities in any participant at any visit. Tolerability and usability data demonstrated that both IVRs were generally highly acceptable.

CONCLUSIONS

Both IVR1 and IVR2 were safe and well tolerated in healthy postmenopausal women. TEAE profiles were comparable to the referent oral regimen.

Evaluation of 28-day estradiol and progesterone vaginal rings in a phase 1 clinical pharmacokinetic study

OBJECTIVE

The aim of this work is to develop a combination of 17β-estradiol (E2) and progesterone (P4) in a single-dose intravaginal ring (IVR) for the treatment of vasomotor symptoms (VMS) and genitourinary syndrome of menopause while providing endometrial protection. The objective of this study was to evaluate DARE-HRT1, a 28-day IVR that continuously delivers E2 and P4, in a phase 1 clinical trial to assess its pharmacokinetics.

METHODS

This was an open-label, three-arm (group) study. Thirty-two (32) healthy postmenopausal women were recruited at two Australian sites. The average age was 57.2 years (47-69 y). The first arm received one ring for 28 days designed to release E2 at a rate of 80 μg/d and P4 at 4 mg/d (80/4 IVR); the second arm received a ring releasing E2 at 160 μg/d and P4 at 8 mg/d (160/8 IVR). The third arm received oral Estrofem (1 mg E2) and Prometrium (100 mg P4) both daily for 29 days. Blood samples were taken predose then intensively over the first day (day 1) and periodically thereafter over the remaining 27 days. After removal of the rings on the morning of day 29, intensive samples were collected. Similar procedures were conducted with women enrolled in the oral group. The plasma samples were analyzed for E2, estrone (E1), and P4 using validated bioanalytical methods.

RESULTS

The baseline-adjusted steady-state plasma levels of E2 and P4 from 80/4 IVR were 20.4 ± 17.1 pg/mL and 1.32 ± 0.19 ng/mL (n = 10), respectively. The baseline-adjusted steady-state plasma levels of E2 and P4 from 160/8 IVR were 30.9 ± 8.7 pg/mL and 2.08 ± 0.50 ng/mL (n = 10), respectively. The baseline-adjusted average plasma concentrations of E2 and P4 at day 29 of the oral group were 35.4 ± 11.2 pg/mL and 0.79 ± 0.72 ng/mL (n = 11), respectively. The baseline-adjusted steady state of E1 from the 80/4 IVR and the 160/8 IVR were 22.1 ± 16.6 pg/mL (n = 10) and 25.2 ± 12.3 pg/mL (n = 10), respectively. The baseline-adjusted concentration of E1 in the oral arm was 209 ± 67.7 ng/mL (n = 11). The IVR were well tolerated, and no serious adverse events were reported.

CONCLUSIONS

The 80/4 IVR and 160/8 IVR gave similar steady-state concentrations of E2 as seen with drug products approved by the US Food and Drug Administration for treatment of VMS and genitourinary symptoms of menopause. The E2 concentrations of this study support the potential of DARE-HRT1, a promising new option for hormone therapy for treatment of VMS and vaginal symptoms associated with menopause.

Intravaginal Drug Delivery Systems to Treat the Genitourinary Syndrome of Menopause: Towards the Design of Safe and Efficacious Estrogen-loaded Prototypes

Estrogens locally delivered to the vagina by tablets, capsules, rings, pessaries, and creams are the most common and highly recommended platforms to treat the genitourinary syndrome of menopause (GSM). Estradiol, an essential estrogen, is routinely administered alone, or in combination with progestins, to effectively alleviate the symptoms associated with moderate to severe menopause when non-pharmacological interventions are not indicated. Since the risk and side effects of estradiol use depends on the administered amount and duration of use, the lowest effective dose of estradiol is recommended when long-term treatment is required. Although there is a wealth of data and literature comparing vaginally administered estrogen-containing products, there is a lack of information revealing the effect of the delivery system used and formulation constituent's attributes on the efficacy, safety, and patient acceptability of these dosage forms. This review therefore aims to classify and compare various designs of commercially available and non-commercial vaginal 17β-estradiol formulations and analyze their performance in terms of systemic absorption, efficacy, safety, and patient satisfaction and acceptance. The vaginal estrogenic platforms included in this review are the currently marketed and investigational 17β-estradiol tablets, softgel capsules, creams, and rings for the treatment of GSM, based on their different design specifications, estradiol loads, and materials used in their preparation. Additionally, the mechanisms of the effects of estradiol on GSM have been discussed, as well as their potential impact on treatment efficacy and patient compliance.

Cost-Effectiveness of perioperative Vaginally Administered estrogen in postmenopausal women undergoing prolapse surgery (EVA trial): study protocol for a multicenter double-blind randomized placebo-controlled trial

BACKGROUND

Surgery for pelvic organ prolapse (POP) is associated with high recurrence rates. The costs associated with the treatment of recurrent POP are huge, and the burden from women who encounter recurrent POP, negatively impacts their quality of life. Estrogen therapy might improve surgical outcome for POP due to its potential beneficial effects. It is thought that vaginal estrogen therapy improves healing and long-term maintenance of connective tissue integrity. Hence, this study aims to evaluate the cost-effectiveness of perioperative vaginal estrogen therapy in postmenopausal women undergoing POP surgery.

METHODS

The EVA trial is a multi-center double-blind randomized placebo-controlled trial conducted in the Netherlands comparing the effectiveness and costs-effectiveness of vaginal estrogen therapy. This will be studied in 300 postmenopausal women undergoing primary POP surgery, with a POP-Q stage of ≥ 2. After randomization, participants administer vaginal estrogen cream or placebo cream from 4 to 6 weeks preoperative until 12 months postoperative. The primary outcome is subjective improvement of POP symptoms at 1 year follow-up, measured with the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes are POP-Q anatomy in all compartments, re-interventions, surgery related complications, general and disease specific quality of life, sexual function, signs and complaints of vaginal atrophy, vaginal pH, adverse events, costs, and adherence to treatment. Follow up is scheduled at 6 weeks, 6 months and 12 months postoperative. Data will be collected using validated questionnaires and out-patient visits including gynecological examination performed by an independent gynecologist.

DISCUSSION

This study investigates whether perioperative vaginal estrogen will be cost-effective in the surgical treatment of POP in postmenopausal women. It is hypothesized that estrogen therapy will show a reduction in recurrent POP symptoms and a reduction in reoperations for POP, with subsequent improved quality of life among women and cost savings. Trial registrationNetherlands Trial Registry: NL6853; registered 19-02-2018, https://www.trialregister.nl/trial/6853 . EudraCT: 2017-003144-21; registered: 24-07-2017.

Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment

Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.

Endometrial safety of low-dose vaginal estrogens in menopausal women: a systematic evidence review

OBJECTIVE

The aim of the study was to systematically review studies that evaluated endometrial hyperplasia or cancer incidence with unopposed vaginal estrogens.

METHODS

PubMed and EMBASE were searched from inception to August 2017 for relevant articles and abstracts. Bibliographies of review articles and abstracts of major women's health medical meetings were examined. Eligible studies (independently reviewed by 4 authors) had to report menopausal vaginal estrogen use and endometrial histology, or incidence of endometrial hyperplasia or cancer.

RESULTS

Of 5,593 abstracts from the literature search and 47 articles from other sources, 36 articles and 2 abstracts were eligible, describing 20 randomized controlled studies, 8 interventional studies, and 10 observational studies. Collectively, the studies did not support an increased risk of endometrial hyperplasia or cancer with low-dose vaginal estrogens. Rates of endometrial cancer and hyperplasia were 0.03% and 0.4%, respectively, from 20 randomized controlled trials (2,983 women) of vaginal estrogens. Overall, reports of endometrial hyperplasia were observed with various doses and durations and appeared sporadic (except 1.25 mg conjugated equine estrogens), consistent with endometrial hyperplasia rates in the general population. A Denmark registry study was an exception and may be of limited applicability to the United States. The Women's Health Initiative Observational Study showed no association (1.3 cases/1,000 women-years with vaginal estrogens versus 1.0/1,000 women-years for nonuse).

CONCLUSION

This systematic review supports the use of low-dose vaginal estrogens for treating vulvar and vaginal atrophy in menopausal women without a concomitant progestogen. This review does not support increased endometrial hyperplasia or cancer risk with low-dose, unopposed vaginal estrogens; however, longer-term, real-world data are needed.

Variation in menopausal vasomotor symptoms outcomes in clinical trials: a systematic review

BACKGROUND

There is substantial variation in how menopausal vasomotor symptoms are reported and measured among intervention studies. This has prevented meaningful comparisons between treatments and limited data synthesis.

OBJECTIVES

To review systematically the outcome reporting and measures used to assess menopausal vasomotor symptoms from randomised controlled trials of treatments.

SEARCH STRATEGY

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to May 2018.

SELECTION CRITERIA

Randomised controlled trials with a primary outcome of menopausal vasomotor symptoms in women and a sample size of at least 20 women per study arm.

DATA COLLECTION AND ANALYSIS

Data about study characteristics, primary vasomotor-related outcomes and methods of measuring them.

MAIN RESULTS

The search identified 5591 studies, 214 of which were included. Forty-nine different primary reported outcomes were identified for vasomotor symptoms and 16 different tools had been used to measure these outcomes. The most commonly reported outcomes were frequency (97/214), severity (116/214), and intensity (28/114) of vasomotor symptoms or a composite of these outcomes (68/214). There was little consistency in how the frequency and severity/intensity of vasomotor symptoms were defined.

CONCLUSIONS

There is substantial variation in how menopausal vasomotor symptoms have been reported and measured in treatment trials. Future studies should include standardised outcome measures which reflect the priorities of patients, clinicians, and researchers. This is most effectively achieved through the development of a Core Outcome Set. This systematic review is the first step towards development of a Core Outcome Set for menopausal vasomotor symptoms.

TWEETABLE SUMMARY

Menopausal hot flushes and night sweats have been reported in 49 different ways in clinical research. A core outcome set is urgently required.

Pharmacokinetics and Tolerability of a Novel 17β-Estradiol and Progesterone Intravaginal Ring in Sheep

This study reports the preparation, in vitro release, pharmacokinetics, and local tolerability of novel ethylene-vinyl acetate intravaginal rings (IVRs) delivering 17β-estradiol (E₂) and progesterone (P), in drug-naïve ovariectomized female Dorset crossbred sheep. After preparation and assessment of in vitro release of E₂ and P, animals were randomized to treatment groups 1 or 2 (comparator rings releasing 50 or 100 μg/d E₂, respectively), groups 3 or 4 (ethylene-vinyl acetate IVRs, 160 μg/d E₂ with 4 [160/4 IVR] or 8 mg/d P [160/8 IVR], respectively), or group 5 (160 μg E₂ and 10 mg P administered intravenously). IVRs were placed on day 1 and remained in place through day 29. Animals underwent daily examinations to confirm ring placement, and vaginal irritation was scored from 0 (none) to 4 (severe). Blood samples were taken at scheduled times for pharmacokinetic analysis. Postmortem examinations performed on groups 1-4 were macroscopic and microscopic evaluations, including irritation scoring and histopathology. IVRs were retained over 28 days in all but 1 animal (group 4). In all animal groups, clinical observations showed no significant abnormal findings. Pharmacokinetic analysis in the animals showed sustained release of E₂ and P over a 28-day period. Irritation scores and microscopic assessments were consistent with foreign object placement. A novel 2-drug IVR delivery system was well tolerated in a sheep model and pharmacokinetic release was as expected over a 28-day release period. These results will guide future human clinical studies.

Solid state 13C NMR spectroscopy provides direct evidence for reaction between ethinyl estradiol and a silicone elastomer vaginal ring drug delivery system

Steroid molecules have a long history of incorporation into silicone elastomer materials for controlled release drug delivery applications. Previously, based on in vitro release testing and drug content analysis, we demonstrated indirectly that the contraceptive progestin levonorgestrel (LNG) chemically and irreversibly binds to addition cure silicone elastomers, presumably via a hydrosilylation reaction between the levonorgestrel ethynyl group and the hydrosilane groups in the poly(dimethylsiloxane-co-methylhydrosiloxane) crosslinker of the silicone elastomer. Here, for the first time, we report that solid state ¹³C nuclear magnetic resonance (NMR) spectroscopy provides direct evidence for the irreversible binding of ethinyl estradiol (EE) - an estrogenic steroid molecule also containing an ethynyl functional group - to an addition cure silicone elastomer. By preparing silicone elastomer samples containing ¹³C-labelled EE, signals in the NMR spectra could readily be assigned to both the free and bound EE. Additional depolymerisation studies, performed on an addition cure silicone elastomer system from which the unbound EE fraction was completely extracted, further confirmed the presence of bound EE through the formation of coloured reaction mixtures resulting from the reaction of bound EE and trifluoroacetic acid (TFA). These methods will be particularly useful in the ongoing development of new steroid-releasing silicone drug delivery devices, including various vaginal ring devices for contraception, HIV prevention and multipurpose prevention technology applications.

ACOG Practice Bulletin No. 141: management of menopausal symptoms

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, with a reported prevalence of 50-82% among U.S. women who experience natural menopause (1, 2). The occurrence of vasomotor symptoms increases during the transition to menopause and peaks approximately 1 year after the final menstrual period (3-5). The purpose of this document is to provide evidence-based guidelines for the treatment of vasomotor and vaginal symptoms related to natural and surgical menopause. (Treatment of menopausal symptoms in cancer survivors is discussed in the American College of Obstetricians and Gynecologists' Practice Bulletin Number 126, Management of Gynecologic Issues in Women With Breast Cancer.).

Undertreatment of menopausal symptoms and novel options for comprehensive management

OBJECTIVE

There is currently a gap in treatment options for menopausal symptoms and a need for comprehensive therapies that are safe and effective for postmenopausal women. This review discusses challenges in the management of menopausal symptoms and the effect of the Women's Health Initiative (WHI) study findings on current treatment patterns. It also examines present and future therapies.

RESEARCH DESIGN AND METHODS

A literature search was conducted using Medline, the Cochrane Database, and the National Heart Lung and Blood Institute WHI website with the following search terms: primary care, menopause, vasomotor symptoms, hormone therapy, osteoporosis, and vaginal atrophy. Searches were limited to articles published between 1995 and 2009.

RESULTS

Comprehensive therapies that target several aspects of menopause, such as vasomotor symptoms and chronic disease prevention, are currently hormone based. These hormone-based approaches are considered more effective than currently available nonhormonal therapies for the relief of menopausal symptoms. However, hormone therapy is not recommended for women at high risk for venous thromboembolic events, cardiovascular disease, and/or breast cancer. A need exists for novel therapies that mitigate menopausal symptoms, provide protection from osteoporosis, and encourage patient compliance without promoting cancer, heart disease, or stroke. Emerging modalities and strategies, such as the tissue selective estrogen complex (TSEC), Org 50081, MF101, and desvenlafaxine, may provide improved options for postmenopausal women.

CONCLUSIONS

Several new menopausal therapies that may help to address the ongoing unmet need for safe and effective therapies for postmenopausal women are currently in development. In particular, the TSEC, which provides the benefits of both a selective estrogen receptor modulator and conjugated estrogens with an improved tolerability profile, may offer advantages over currently available treatment options. Limitations of this review include the narrow search criteria and limited search period.

Comparative controlled trial of a novel oral estrogen therapy, estradiol acetate, for relief of menopause symptoms

OBJECTIVE

To compare the efficacy and tolerability of a new oral estradiol prodrug, estradiol acetate, with micronized estradiol or conjugated equine estrogens for alleviation of postmenopausal vasomotor and urogenital symptoms.

DESIGN

A total of 249 postmenopausal women experiencing seven or more moderate or severe vasomotor symptoms daily for 1 week or 60 or more symptoms in 1 week were randomized to 0.9 mg of estradiol acetate (n = 79), 1 mg of micronized estradiol (n = 85), or 0.625 mg of conjugated equine estrogens therapy (n = 85). Efficacy endpoints were the change in frequency and severity of vasomotor symptoms from baseline to week 12, participant-assessed urogenital symptoms, and investigator-assessed signs of vaginal atrophy. Efficacy results were considered equivalent if estradiol acetate was at least 80% as effective as estradiol and conjugated estrogens.

RESULTS

At week 12, frequency of vasomotor symptoms decreased comparably in all groups, and at weeks 4 and 12, the decrease in frequency of symptoms was statistically equivalent for estradiol acetate and conjugated estrogens. Severity of vasomotor symptoms also improved comparably for all groups, with least squares mean decreases of 1.05 for estradiol acetate, 1.34 for estradiol, and 1.17 for conjugated estrogens at week 12. Urogenital symptoms and vaginal signs showed similar improvement in all groups. Overall, the majority of adverse events were mild or moderate and consistent with estrogen therapy.

CONCLUSION

Estradiol acetate 0.9 mg was comparable to 1 mg of estradiol and 0.625 mg of conjugated equine estrogens in reducing the number and severity of vasomotor and urogenital symptoms in postmenopausal women. Oral estradiol acetate was well tolerated.

Bone mineral density in postmenopausal women treated with a vaginal ring delivering systemic doses of estradiol acetate

OBJECTIVE

To evaluate the effect on bone mineral density of vaginal rings delivering estradiol acetate at two systemic doses versus a locally active vaginal ring in healthy postmenopausal women.

DESIGN

A total of 174 postmenopausal women (younger than age 65 years) were randomly assigned to a 0.05 mg/day vaginal ring, 0.1 mg/day vaginal ring, or 0.0075 mg/day vaginal ring (active comparator), and treated for 96 weeks. Of these, 170 took a study drug; 85 taking the study drug had data at 96 weeks, and 132 women were included in the intent-to-treat analysis. Non-hysterectomized women received 1 mg of norethisterone taken on the last 12 days of each 28-day monthly cycle. The primary endpoint was change in lumbar spine bone mineral density (L2-L4); change in total hip bone mineral density was a secondary endpoint.

RESULTS

At 96 weeks, mean lumbar spine bone mineral density increased 2.7% and 3.3% from baseline, respectively, in the 0.05-mg and 0.1-mg groups (P < 0.001 for both) compared with an 0.3% increase in the 0.0075-mg group (P = 0.56). Mean total hip bone mineral density increased 1.7% and 1.8% from baseline, respectively, in both the 0.05-mg and 0.1-mg groups (P < 0.001) and decreased 1.2% in the 0.0075-mg group (P = 0.001). All vaginal ring doses were well tolerated.

CONCLUSIONS

Vaginal rings delivering systemic doses of estradiol increase bone mineral density of the lumbar spine and total hip in healthy postmenopausal women. Safety and acceptability were similar to existing estradiol therapies.

Why consider vaginal drug administration?

OBJECTIVE

To review the anatomy and physiology of the vagina, the merits of vaginal drug administration, and the currently available vaginal drug-administration systems.

DESIGN

Review of basic and clinical research.

RESULT(S)

Although clinicians commonly use topically administered drugs in the vagina, this route for systemic drug administration is somewhat novel. Experience with a variety of products demonstrates that the vagina is a highly effective site for drug delivery, particularly in women's health. The vagina is often an ideal route for drug administration because it allows for the administration of lower doses, steady drug levels, and less frequent administration than the oral route. With vaginal drug administration, absorption is unaffected by gastrointestinal disturbances, there is no first-pass effect, and use is discreet. Knowledge of anatomy, physiology, histology, and immunology of the vagina should allow clinicians to reassure their patients concerning this mode of delivery. Greater understanding and experience by clinicians should lead to increased use and acceptance of the vagina as a route for drug administration.

CONCLUSION(S)

The safety and efficacy of vaginal administration have been well established. The vaginal route of drug delivery is acceptable and may even be a preferable route of administration for many drugs, particularly hormones, whether for contraception or postmenopausal estrogen therapy.

Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society

OBJECTIVE

To create an evidence-based position statement regarding the treatment of vasomotor symptoms associated with menopause.

DESIGN

The North American Menopause Society (NAMS) enlisted clinicians and researchers acknowledged to be experts in the field of menopause-associated vasomotor symptoms to review the evidence obtained from the medical literature and develop a document for final approval by the NAMS Board of Trustees.

RESULTS

For mild hot flashes, lifestyle-related strategies such as keeping the core body temperature cool, participating in regular exercise, and using paced respiration have shown some efficacy without adverse effects. Among nonprescription remedies, clinical trial results are insufficient to either support or refute efficacy for soy foods and isoflavone supplements (from either soy or red clover), black cohosh, or vitamin E; however, no serious side effects have been associated with short-term use of these therapies. Single clinical trials have found no benefit for dong quai, evening primrose oil, ginseng, a Chinese herbal mixture, acupuncture, or magnet therapy. Few data support the efficacy of topical progesterone cream; safety concerns should be the same as for other progestogen preparations. No clinical trials have been conducted on the use of licorice for hot flashes. Among nonhormonal prescription options, the antidepressants venlafaxine, paroxetine, and fluoxetine and the anticonvulsant gabapentin have demonstrated some efficacy for treating hot flashes and were well tolerated. Two antihypertensive agents, clonidine and methyldopa, have shown modest efficacy but with a relatively high rate of adverse effects. For moderate to severe hot flashes, systemic estrogen therapy, either alone (ET) or combined with progestogen (EPT) or in the form of estrogen-progestin oral contraceptives, has been shown to significantly reduce hot flash frequency and severity. Clinical trials have associated ET/EPT with adverse effects, including breast cancer, stroke, and thromboembolism. Several progestogens (both oral and intramuscular formulations) have shown efficacy in treating hot flashes, including women with a history of breast cancer, although no definitive data are available on long-term safety in these women.

CONCLUSIONS

In women who need relief for mild vasomotor symptoms, NAMS recommends first considering lifestyle changes, either alone or combined with a nonprescription remedy, such as dietary isoflavones, black cohosh, or vitamin E. Prescription systemic estrogen-containing products remain the therapeutic standard for moderate to severe menopause-related hot flashes. Recommended options for women with concerns or contraindications relating to estrogen-containing treatments include prescription progestogens, venlafaxine, paroxetine, fluoxetine, or gabapentin. Clinicians are advised to enlist women's participation in decision making when weighing the benefits, harms, and scientific uncertainties of therapeutic options. Regardless of the management strategy adopted, treatment should be periodically reassessed as menopause-related vasomotor symptoms will abate over time without any intervention in most women.