Contemporary Management of Menopausal Vasomotor Symptoms: An Evidence-Based Review of Hormonal and Non-Hormonal Interventions

Objective: To synthesize current evidence regarding the pathophysiology, clinical evaluation, and global management guidelines for vasomotor symptoms (VMS), providing a structured, cross-cultural approach to personalized menopause care.Mechanism:Central pathophysiology is driven by midlife estrogen depletion, which induces hypothalamic noradrenergic hyperactivity and neurochemical imbalance alongside hyperactive kisspeptin, neurokinin B, and dynorphin (KNDy) neurons in the arcuate nucleus. Excessive neurokinin B stimulates neurokinin 3 (NK3) receptors, resulting in a structurally narrowed thermoneutral zone and acute vasomotor instability.Findings in Brief:Diagnosis remains primarily clinical. Menopausal Hormone Therapy (MHT) is established as the most effective treatment, particularly when initiated within the “timing window” (aged <60 years or within 10 years of onset), utilizing the lowest effective dose and transdermal administration to mitigate thromboembolic risks. For patients with contraindications, evidence-based non-hormonal options—including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentinoids, newly Food and Drug Administration (FDA)-approved NK3 receptor antagonists (e.g., fezolinetant), and structured plant-based dietary restructuring—offer substantial symptom reduction. Additionally, behavioral therapies such as Cognitive Behavioral Therapy (CBT) and clinical hypnosis serve as valuable adjuncts for improving quality of life.Conclusions:Effective clinical management of menopausal symptoms requires moving away from standardized one-size-fits-all protocols. By integrating lifestyle modifications, targeted pharmacotherapy, and patient preferences, clinicians can optimize efficacy, and overall quality of life throughout the menopausal transition. This review underscores the importance of using the lowest effective dose and favoring transdermal administration to mitigate risks, thereby supporting a comprehensive, evidence-based approach to the menopausal transition.