The most appropriate management of this patient is a combination of oral estradiol and progestin. Severe vasomotor symptoms are best treated with systemic hormone therapy. An individualized approach based on personal risk factors (including age, time since menopause, and absence of increased risk for cardiovascular disease, thromboembolism, or breast cancer) suggests that this patient is an appropriate candidate. The absolute risks associated with hormone therapy use in healthy women younger than 60 years are low, as are the risks of adverse cardiovascular events if time since menopause is less than 10 years. Estradiol can be administered orally or transdermally in gel, patch, or spray; progestin is needed to prevent endometrial proliferation in this patient with an intact uterus.

Treatment should begin with the lowest effective dose needed to achieve symptom relief. Systemic hormone therapy treats the symptoms present in this patient, including severe hot flushes, vaginal atrophy, and mood swings. Dose, duration, and route of systemic hormone therapy should be based on symptom response, individualized risk stratification, and patient preference. Because treatment duration greater than 5 years is associated with increased breast cancer risk, the need for treatment should be reassessed annually.

A patient who is amenorrheic for more than 12 months is, by definition, menopausal. Therefore, measuring a serum follicle-stimulating hormone level will not alter management and represents unnecessary and low value care.

Measurement of serum estrogen levels in this patient would not be helpful in guiding therapy. The treatment of vasomotor symptoms in a menopausal patient is based on clinical presentation and response to treatment, and laboratory studies are not routinely indicated before starting therapy.

Low-dose selective serotonin reuptake inhibitors (SSRIs) such as paroxetine have been shown to alleviate vasomotor symptoms. However, nonhormonal agents such as SSRIs or gabapentin will not alleviate this patient's symptoms of vaginal atrophy and dyspareunia.

Vaginal estradiol will alleviate symptoms of vaginal atrophy; however, local therapy will not relieve her severe hot flushes and mood changes. Therefore, systemic hormone therapy is a better choice for this patient.