Transdermal estradiol without a progestin is the most appropriate choice for this patient with severe vasomotor symptoms of menopause that are refractory to conservative treatment and are affecting her quality of life. Systemic estrogen improves both hot flushes and genitourinary symptoms. She has had a hysterectomy and therefore does not require the use of a progestin to oppose the proliferative effects of estrogen on the endometrium, making therapy with estrogen alone an appropriate treatment option.

The use of hormones to treat menopausal symptoms requires balancing potential benefits and risks, and an individualized risk profile must be considered. This patient is recently menopausal, younger than 60 years, and does not have a history of thromboembolism or cardiac disease or have an increased risk for breast cancer. Treatment with systemic estrogen would be a reasonable choice and can be administered orally or transdermally by patch, gel, or spray. There is some evidence that transdermal estrogen may be associated with less thromboembolic risk than oral estrogen by avoiding the hepatic first-pass effect. All formulations are equally effective for treating vasomotor symptoms.

Current evidence does not support the use of progestin alone to treat vasomotor symptoms. Although progestins may improve vasomotor symptoms, safety data for progestin alone are lacking. Also, in the Women's Health Initiative, the risk of breast cancer was increased in the estrogen and medroxprogesterone acetate arm, but not in the estrogen-alone arm, raising concern that the risk of breast cancer may be related to progestin use. Therefore, a progestin alone is not the most appropriate choice for the management of vasomotor symptoms.

Vaginal estradiol therapy is useful in treating menopausal genitourinary symptoms, including dryness, itching, dysuria, and dyspareunia. However, local topical treatment does not alleviate vasomotor or other systemic menopausal symptoms. In this patient who has both vaginal symptoms and severe vasomotor symptoms, vaginal treatment alone would not be adequate.