Menopause medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [6] Rahmah Al-Edresi, M.D.[7]
Overview
While perimenopause is a natural stage of life when the symptoms are severe, this may be alleviated through medical treatments that include Hormone therapy(HT), non-hormonal therapy, and complementary or alternative therapies.Hormonal therapy (HT) provides the best relief, but hormone therapy should only be used for the shortest duration of time and at its lowest effective dose, as it increases the relative risk of pelvic cancer, breast cancer, thromboembolism, and coronary heart disease, especially in women who start HT after menopause. Some other drugs afford limited relief from hot flashes. A woman and her doctor should carefully review her symptoms and relative risk before determining whether the benefits of HT or other therapies outweigh the risks.
Medical therapy
- Hormone therapy
In addition to relief from hot flashes, hormone therapy (HT) remains an effective treatment for osteoporosis. In HT, estrogens, progesterone or other hormones are administered to compensate for the body's own insufficiency to produce them. There are several types of therapies, with various side effects.
Conjugated equine estrogens
Conjugated equine estrogens contain estrogen molecules conjugated to hydrophilic side groups (e.g. sulfate) and are produced from Equidae-animals (horses).
Adverse effects
Women had been advised for many years that hormone therapy after menopause might reduce their risk of heart disease and prevent various aspects of aging. However, a large, randomized, controlled trial (the Women's Health Initiative) found that women undergoing HT with conjugated equine estrogens (Premarin), whether or not used in combination with a progestin (Premarin plus Provera), had, statistically-speaking, a slightly increased risk of breast cancer, heart disease, stroke, and Alzheimer's disease sufficient to justify stopping the study.
After these results were reported in 2002, the number of prescriptions written for Premarin and PremPro in the United States dropped almost in half, as many women discontinued HT altogether. The sharp drop in prescriptions for Premarin and PremPro following the mid-2002 announcement of their dangers was followed by large and successively greater drops in new breast cancer diagnoses at six months, one year, and 18 months after that announcement, for a cumulative 15% drop by the end of 2003. Surprisingly, no similar drop in Canada's breast cancer rates was observed during the same period, though prescriptions of PremPro and Premarin were reduced in Canada as well. Studies designed to track the further progression of this trend after 2003 are underway, as well as to determine if the drop is related to the reduced use of HRT.
Other forms of hormone therapy
Due to the controversy about Premarin-based hormone therapy, a number of doctors are now moving patients who request hormone therapy to help them through perimenopause, to bioidentical hormone products such as Estrace, a form of the precursor to estrogen in the human body known as estradiol, which have produced fewer side effects than conjugated equine estrogens[1].
However, all hormone replacement therapies probably do carry some health risks, including high blood pressure, blood clots, and increased risks of breast and uterine cancers. Women who have had a hysterectomy seem to tolerate estrogen-only therapy better than mixed-hormone therapy, and reduce the breast cancer risk brought on by progestin supplementation.
The anti-seizure medication gabapentin (Neurontin) seems to be second only to HRT in relieving hot flashes.
- Non Hormonal therapy
- Antidepressants
Antidepressants such as paroxetine (Paxil), Fluoxetine hydrochloride (Prozac), and Venlafaxine hydrochloride (Effexor) have been used with some success in the treatment of hot flashes, improving sleep, mood, and quality of life. Of these, Paxil has been the most studied and may provide the most consistent relief. There is a theoretical reason why SSRI antidepressants might help with memory problems-- they increase circulating levels of the neurotransmitter serotonin in the brain and restore hippocampal function. Prozac has been repackaged as Sarafem and is approved and prescribed for premenstrual dysphoric disorder (PMDD), a mood disorder often exacerbated during perimenopause and early menopause. PMDD has been found by PET scans to be accompanied by a sharp drop in serotonin in the brain and to respond quickly and powerfully to SSRIs.
- Blood pressure medicines
About as effective as antidepressants for hot flashes, but without the other mind and mood benefits of antidepressants, are blood pressure medicines including clonidine (Catapres). These drugs may merit special consideration by women suffering both from high blood pressure and hot flashes.
- Complementary and alternative therapies
It should be noted that medical non-hormone treatments provide less than complete relief, and each has side effects.
In the area of complementary and alternative therapies, acupuncture treatment is promising. There are some studies indicating positive effects, especially on hot flashes [2][3][4] but also others [5] showing no positive effects of acupuncture regarding menopause.
There are claims that soy isoflavones are beneficial concerning menopause. However, a study [6] indicated that soy isoflavones did not improve or appreciably affect cognitive functioning in postmenopausal women.
Other remedies that have proven no better than a placebo at treating hot flashes and other menopause symptoms include red clover isoflavone extracts and black cohosh. Black cohosh has potentially serious side-effects such as the stimulation of breast cancer, therefore prolonged administration is not recommended in any case.
Other therapies
Individual counseling or support groups may be helpful to handle sad, depressed, or confusing feelings women may be having as their bodies change. Vaginal moisturizers such as Vagisil or Replens, can help women with thinning vaginal tissue or dryness. Lubricants, such as K-Y Jelly or Astroglide, can help with lubrication difficulties that may be present during intercourse. Moisturizers and lubricants are different products for different types of issues. Some women feel dry apart from sex and they may do better with moisturizers all the time. Those who just need lubricants are fine just using the lubrication products during intercourse. Low-dose vaginal estrogen is generally a safe way to take estrogen to solve vaginal thinning and dryness problems while only minimally increasing the levels of estrogen in the blood.
Obvious measures, such as drinking cold liquids and removing excess clothing layers when hot flashes strike, and avoiding hot flash triggers such as spicy foods, may supplement or supplant the use of medications for some women.
References
- ↑ "Bioidentical Hormones Come Of Age", Marcelle Pick, OB/GYN Nurse Practitioner; published March 24, 2004; updated June 7, 2007; retrieved June 13, 2007.
- ↑ [1] Nir Y, Huang MI, Schnyer R, Chen B, Manber R. Stanford University School of Medicine, United States. amiryael@gmail.com
- ↑ [2] Cohen SM, Rousseau ME, Carey BL. University of Pittsburgh, 440 Victoria Bldg, 3500 Victoria St, Pittsburgh, PA 15261, USA. cohensu@pitt.edu
- ↑ [3] Zaborowska E, Brynhildsen J, Damberg S, Fredriksson M, Lindh-Astrand L, Nedstrand E, Wyon Y, Hammar M. Division of Obstetrics and Gynecology, Department of Molecular and Clinical Medicine, Faculty of Health Sciences, University Hospital, Linköping, Sweden.
- ↑ [4] Vincent A, Barton DL, Mandrekar JN, Cha SS, Zais T, Wahner-Roedler DL, Keppler MA, Kreitzer MJ, Loprinzi C. Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
- ↑ [5] Fournier LR, Ryan Borchers TA, Robison LM, Wiediger M, Park JS, Chew BP, McGuire MK, Sclar DA, Skaer TL, Beerman KA. Department of Psychology, Washington State University, Pullman, WA 99164-4820, USA. Fournier@wsunix.wsu.edu