The use of the intrauterine device releasing Levonorgestrel (LNG-IUD) may be an alternative and effective approach, thus recent studies suggest higher rate of regression in the presence of complex endometrial hyperplasia (with or without atypias) and less hysterectomies compared to oral progestins.

Tranexamic acid, non-steroidal anti-inflammatory drugs (NSAIDs), Danazol, GnRH analogues, and selective progesterone receptor modulators (SPRMs) may be other pharmacological compounds in symptomatic patients presenting persistent dysfunctional bleeding. Surgical endometrial ablation may be effective in patients who are not responsive to pharmacological strategies [9–13].

Vasomotor symptoms (VMS) such as hot flushes and cold or night sweats are common transitional symptoms, which usually decline throughout the postmenopausal life; however, they are bothersome symptoms that affect nocturnal sleep and deteriorate quality of life.

Hot flushes are more frequent during the early phases of sleep and contribute to sleep disruption and long-term onset of anxiety, depressed mood, and sexual dysfunction. VMS and consequent sleep disturbance are bothersome symptoms and are often common reasons for midlife women to seek for the first time medical attention on menopausal transition problems.

Hypothalamic insensitivity to estrogens also explains why menopausal symptoms commonly appear during this transition, when women have rather high levels of estrogens, as well as why exogenous estrogens are effective in reducing the symptoms [12].

Estrogen withdrawal also results in higher frequency of osteopenia, osteoporosis, urogenital symptoms and, in the long term, in increased risk of cardiovascular diseases (CVD), metabolic syndrome, and cognitive decline [14].

Estrogen deficiency is the principal pathophysiologic mechanism that underlies the spectrum of these menopausal symptoms, and various estrogen formulations are prescribed as hormonal replacement therapy (HRT), which remains the most efficacious of available therapeutic options for alleviating the symptom burden of menopause. The addition of progesterone to estrogen in HRT aims to protect women with intact uteri against endometrial pathologies, including hyperplasia and cancer.

A potential for symptomatic benefit with any treatment option must take into consideration the nature and severity of a woman’s problems and be weighed against assessed treatment-related risks, individualized from the perspective of each patient’s exclusive health profile. Choice of therapy should additionally take into consideration an individual woman’s perspective and preferences (Tables 19.2 and 19.3).