Menopausal symptoms
Symptom complex from declining ovarian function: hot flashes, night sweats, sleep disturbance, mood swings, genitourinary syndrome. Menopausal hormone therapy (MHT) is the evidence-based option for pronounced symptoms in women under 60 or within 10 years of menopause.
ICD-10 N95.16 drugs
Also known as: Menopausal syndrome, Vasomotor symptoms
Drugs used for this condition
- AEstradiolFirst line · Estrogens — natural and semisyntheticFirst-line for moderate-to-severe vasomotor menopausal symptoms (hot flashes, night sweats, sleep disturbance) in women under 60 or within 10 years of menopause per NAMS 2022, IMS 2016, BMS 2024. In women with an intact uterus, combine with a progestogen (micronized progesterone or dydrogesterone) is mandatory. In hysterectomized women, estradiol monotherapy. Transdermal preferred over oral in patients with VTE risk, migraine with aura, or hepatic disease.
- AProgesterone, micronizedFirst line · Progestogens — progesterone derivativesIn women with an intact uterus on MHT, micronized progesterone provides endometrial protection and offers mild anxiolytic and sleep-promoting effects, often welcomed by patients. French E3N and EPIC data suggest lower breast cancer risk with micronized progesterone in MHT versus synthetic progestins.
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
- DDehydroepiandrosterone (DHEA, prasterone)Not recommended · Endogenous C19 steroid precursor; an EU prescription drug for adrenal insufficiency and a vaginal form (Intrarosa); a freely available supplement in the United StatesDHEA is promoted as a «natural alternative» to menopausal hormone therapy. Oral systemic intake is ineffective for hot flushes: NICE 2024 and IMS 2024 do not recommend it for systemic menopausal symptoms. Vaginal prasterone (Intrarosa) is approved by AEMPS and EMA for moderate-to-severe vulvovaginal atrophy – a narrow local indication, not «rejuvenation». Oral systemic DHEA from US and iHerb stores is not registered in Spain. For hot flushes, night sweats or dryness in menopause, discuss with a gynaecologist the standard MHT (first-line therapy) or alternatives from NICE 2024.
- DHypericum perforatumNot recommended · Antidepressants. Other antidepressants of herbal originSt. John's wort is offered for hot flushes, menopausal complaints and premenstrual syndrome. The data are weak and inconsistent: several small trials and one meta-analysis show modest improvement in hot flushes and mood, but there is no large high-quality confirmation, and menopause guidelines do not list it as a first choice. Safety matters too: the herb lowers the effectiveness of hormone therapy and oral contraceptives by speeding their breakdown. For menopausal symptoms and PMS it is more sensible to discuss options with proven benefit with a doctor.
- FBlack cohosh (Cimicifuga racemosa)Not recommended · Herbal product for menopausal symptoms (food supplement under Spanish RD 1487/2009)Marketing promotes black cohosh as a complete replacement for menopausal hormone therapy (MHT). There is no such replacement: MHT addresses estrogen deficiency, while black cohosh has no estrogenic activity and does not correct osteoporosis, urogenital atrophy or cardiovascular risk. EMA HMPC 2007 described rare but clinically meaningful cases of idiosyncratic hepatitis, including fulminant, on black cohosh. In patients with estrogen-receptor-positive breast or endometrial cancer the product is not recommended. If a doctor framed black cohosh as a natural replacement for MHT or suggested a long course without ALT/AST monitoring, consider seeking a second opinion from another gynaecologist. If jaundice, dark urine, right-upper-quadrant pain or unexplained fatigue appears, stop the supplement and contact a doctor.
- FDong quai (Angelica sinensis)Not recommended · Traditional Chinese medicine herbal product (food supplement under Spanish RD 1487/2009)Dong quai is a traditional Chinese medicine product sold for menopausal symptoms. There is no quality evidence for dong quai: the only double-blind RCT (Hirata 1997, 71 patients) showed no advantage over placebo on hot flashes or endometrial thickness. Systematic reviews from NICE NG23 and Memorial Sloan Kettering 2024 classify dong quai as a product without confirmed efficacy. SEGO 2024 does not recommend it. If hot flashes are troubling, discuss evidence-based options with the gynaecologist (MHT, SSRIs, gabapentin, clonidine) – dong quai is not among them.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit