Research · PMID 36749328
Reviewed by Neal Rouzier, MD, Preventive Medicine · Sep 2026
Management of Menopausal Symptoms: A Review.
JAMA · February 2023 · Carolyn J Crandall, Jaya M Mehta, JoAnn E Manson
What this study found
Menopause, due to loss of ovarian follicular activity without another pathological or physiological cause, typically occurs between the ages of 45 years and 56 years. During the menopausal transition, approximately 50% to 75% of women have hot flashes, night sweats, or both (vaso
How RAGMD uses this study
Clinical questions this paper informs
Synthesis lives on the evidence question — this page shows where the study sits in that analysis.
Primary study
What therapies are most effective for vasomotor symptoms in perimenopause?
Systemic hormone therapy remains the most effective treatment for moderate-to-severe vasomotor symptoms across the menopause transition. When estrogen is declined or contraindicated, evidence-supported non-hormonal options—including fezolinetant and selected SSRIs/SNRIs—reduce symptoms, though with generally smaller effect than estrogen.
Open evidence analysisSupporting literature
Does hormone replacement therapy reduce cardiovascular risk in early menopause?
The timing hypothesis suggests earlier initiation may differ from late initiation, where WHI showed harm for combined therapy. Current guidelines emphasize individualized risk assessment rather than routine cardioprotection.
Open evidence analysisSupporting literature
Does hormone replacement therapy increase venous thromboembolism risk?
Oral estrogen increases venous thromboembolism risk compared with no therapy. Transdermal estrogen appears to carry lower thrombotic risk in observational studies and is often preferred in women at elevated VTE risk.
Open evidence analysisSupporting literature
Is there a critical timing window for cardiovascular benefit from HRT?
The critical-window concept proposes that starting HRT closer to menopause may yield different cardiovascular effects than starting later. WHI subgroup analyses inform but do not prove this hypothesis for routine practice.
Open evidence analysisSupporting literature
Is progestogen required to protect the endometrium with estrogen therapy?
Systemic estrogen in women with a uterus requires adequate progestogen exposure to prevent endometrial hyperplasia. Micronized progesterone and progestins differ in metabolic and VTE profiles.
Open evidence analysisSupporting literature
Are bioidentical hormone preparations safer or more effective than conventional HRT?
FDA-approved bioidentical estradiol and progesterone have trial and post-marketing data. Custom-compounded bioidentical combinations lack equivalent efficacy and safety evidence and are not recommended over approved products by major societies.
Open evidence analysisSupporting literature
Does low-dose vaginal estrogen carry significant systemic risks?
Low-dose vaginal estrogen for genitourinary syndrome of menopause achieves local benefit with minimal systemic absorption in most women. Progestogen is generally not required for endometrial protection at standard low doses.
Open evidence analysisSupporting literature
Does hormone therapy prevent cognitive decline or dementia?
WHI and subsequent analyses do not support HRT for dementia prevention when initiated in older postmenopausal women. Early-initiation cognitive studies are mixed and do not establish routine neuroprotection.
Open evidence analysisSupporting literature
What is the evidence for hormone and metabolic therapy in PCOS?
PCOS management prioritizes lifestyle intervention, cycle regulation, and treatment of hyperandrogenism and metabolic risk. Metformin and hormonal contraceptives have evidence for specific endpoints; individualized plans depend on fertility goals.
Open evidence analysisSupporting literature
Is fezolinetant effective for menopausal hot flashes?
Fezolinetant, a neurokinin-3 receptor antagonist, reduced moderate-to-severe vasomotor symptoms in randomized trials of postmenopausal women. It offers a non-hormonal option when estrogen is contraindicated or declined.
Open evidence analysisSupporting literature
Does menopausal hormone therapy prevent osteoporosis and fractures?
Estrogen-based therapy reduces bone loss and fracture risk in postmenopausal women, with benefit most established during early postmenopause. Guidelines support HRT for fracture prevention primarily when indicated for vasomotor symptoms or in high-risk women.
Open evidence analysisSupporting literature
Does hormone therapy improve sleep disturbance in menopause?
Menopausal hormone therapy can improve sleep when vasomotor symptoms are a major driver of disruption. Benefits for primary insomnia without hot flashes are less consistent across trials.
Open evidence analysisSupporting literature
What is the evidence for treating genitourinary syndrome of menopause?
Low-dose vaginal estrogen effectively treats vaginal dryness, dyspareunia, and urinary symptoms of genitourinary syndrome of menopause with minimal systemic exposure. Regular reassessment of endometrial safety applies at higher cumulative doses.
Open evidence analysisSupporting literature
Does testosterone therapy improve sexual function in postmenopausal women?
Testosterone therapy modestly improves sexual desire and related distress in selected postmenopausal women with hypoactive sexual desire disorder, particularly after oophorectomy. Monitoring for androgenic side effects and long-term safety is recommended.
Open evidence analysisSupporting literature
Should women with early surgical menopause receive hormone therapy?
Women with premature or early surgical menopause should generally receive hormone therapy until the average age of natural menopause unless contraindicated, to mitigate bone, cardiovascular, and symptom burden associated with early estrogen loss.
Open evidence analysisSupporting literature
How long should menopausal hormone therapy be continued?
Duration should be individualized based on symptom control, indication, and evolving risks. Many guidelines support continued use with annual reassessment rather than arbitrary stopping ages when benefits outweigh risks for that patient.
Open evidence analysisSupporting literature
Does hormone therapy help depression or anxiety during perimenopause?
Some trials suggest estrogen-based therapy may help depressive symptoms during the menopause transition, particularly when vasomotor symptoms coexist. It is not a substitute for standard treatment of major depressive disorder.
Open evidence analysisSupporting literature
Is menopause associated with cognitive changes or brain fog?
Many women report subjective cognitive difficulty during perimenopause, often linked to sleep disruption and vasomotor symptoms. Objective cognitive testing shows subtle changes in some cohorts, but HRT is not established as a treatment for brain fog alone.
Open evidence analysisSupporting literature
Does menopause cause weight gain and can hormone therapy help?
Menopause is associated with central adiposity and lean mass loss independent of aging alone. Hormone therapy is not a weight-loss treatment but may attenuate some menopause-related body composition shifts in selected women.
Open evidence analysisSupporting literature
Is transdermal estrogen preferred over oral estrogen in menopause?
Transdermal estrogen avoids first-pass hepatic effects and is associated with lower venous thromboembolism risk than oral routes in observational data. It is often preferred in women with elevated thrombotic or metabolic risk.
Open evidence analysisSupporting literature
Can GLP-1 therapy be combined safely with hormone optimization regimens?
No large outcome trials specifically study combined GLP-1 and hormone therapy. Clinically, combinations are used with attention to muscle mass, nutritional status, and individual cardiometabolic goals.
Open evidence analysis