Summary: Vasomotor and vaginal symptoms are cardinal symptoms of menopause. Vasomotor symptoms can be particularly troubling to women and are the most commonly reported menopausal symptoms, with a reported prevalence of 50-82% among U.S. women who experience natural menopause (1, 2). The occurrence of vasomotor symptoms increases during the transition to menopause and peaks approximately 1 year after the final menstrual period (3-5).
Today’s New York Times has an interesting take on menopause. Here it is:
In the-better-late-than-never department, the American College of Obstetricians and Gynecologists has revised its guidelines for effective treatment of the symptoms of menopause. Published as a practice bulletin for doctors called “Management of Menopausal Symptoms,” the new guidelines recognize that up to three-fourths of women in the United States experience troublesome side effects when their bodies stop producing estrogen as a result of natural or medically induced menopause. The document addresses the most common distressing consequences: hot flushes and vaginal atrophy.
- Hot flushes can last for months or even decades, but vaginal problems, if untreated, persist for the remainder of a woman’s life.
- Hot flushes can cause drenching, sometimes embarrassing sweating, and seriously disrupt sleep night after night. Vaginal atrophy and the loss of lubrication and elasticity can make sexual encounters painful, depress libido and cause irritation and bleeding during exercise.
You might think the standard treatment would be to administer the hormones that menopausal women are losing. Indeed, supplementation with estrogen was a common practice for decades, and not just for curbing menopausal symptoms. Estrogen was widely promoted as a way to protect women’s health and to keep looking and feeling young well into old age.
But in 2002, a large clinical trial called the Women’s Health Initiative found that the most popular form of hormone replacement, a pill that combined estrogen and synthetic progesterone called Prempro, increased a woman’s risk of heart disease, breast cancer, stroke and blood clots .
The highly publicized results tainted hormone therapy with a broad brush. Although the Women’s Health Initiative was designed primarily to test the popular premise that hormone replacement after menopause protected women’s hearts, the unexpected findings prompted millions of middle-aged and older women to stop using the hormones and kept many millions more from starting them. Even though the vast majority of the 16,608 participants in the study were older women well past menopause, the findings were widely interpreted to apply to all women going through menopause, even younger women just approaching the end of their fertile years.
Somewhat frenetic experimentation ensued as physicians, drug companies and women themselves searched for effective alternatives to hormone replacement. Various nonhormonal remedies were promoted, from soy foods and black cohosh to exercise and acupuncture. Each had its advocates, but all lacked rigorous scientific evidence for effectiveness.
Those promoting soy-based foods and supplements, for example, cited the low reported rates of menopausal symptoms among Asian women, whose diets are especially rich in soy, which has estrogenic effects. An authoritative review of placebo-controlled studies of plant-based estrogens, however, found no convincing evidence that they were helpful in curbing menopausal hot flushes. (One exception was genistein, a substance in soy, which the researchers said warranted further study.)
The new bulletin, prepared by Dr. Clarisa R. Gracia, an associate professor of obstetrics and gynecology at the University of Pennsylvania, examines the various claims and scores of studies. It offers treatment recommendations based on the best available evidence for preserving the health and well-being of women experiencing menopausal symptoms.
In an interview, Dr. Gracia acknowledged that “there’s a strong placebo effect” when women try one or another suggested remedy for menopausal distress. She admitted that “it’s all for the better” if an innocuous placebo, like a food or supplement, brings relief to some women.
But most women do best when their physicians offer remedies that have been shown to be effective in well-designed studies. And as you might guess, estrogen alone, or in combination with a natural or synthetic progesterone (progestin) for women who still have a uterus, is the “most effective therapy” for curbing hot flushes, the report found.
- “Data do not support the use of progestin-only medications, testosterone or compounded bioidentical hormones,” the report also said.
- Estrogen with or without progestin can be administered orally or through the skin with a patch, gel or spray. The transdermal route is considered safer: When absorbed through the skin, the hormones bypass the liver, which would otherwise create substances that might raise the risk of heart attack or cancer.
- The report emphasizes that treatment with hormones must be individualized and that doctors should prescribe the lowest effective dose for the shortest time needed to relieve hot flushes. But because some women may need hormone therapy to control hot flushes even in their Medicare years, the guidelines recommend “against routine discontinuation of systemic estrogen at age 65.”
- Hormone replacement can be risky for some women, especially those who have had breast cancer. Alternatives that have proved helpful include low doses of antidepressants known as selective serotonin reuptake inhibitors (S.S.R.I.’s), like Paxil, and serotonin-norepinephrine reuptake inhibitors (S.N.R.I.’s), like Pristiq. Clonidine, a blood pressure medication, and gabapentin, an anticonvulsant, may also be helpful, though neither is approved by the Food and Drug Administration for menopausal treatment.
- The report found little or no data to support the use of herbal remedies, vitamins, phytoestrogens (like isoflavones, soy and red clover) or acupuncture to relieve hot flushes. It did recommend “common sense lifestyle solutions” like dressing in layers, lowering room temperatures, consuming cool drinks, and avoiding alcohol and caffeine. For overweight and obese women, weight loss can also help.
- As with hot flushes, vaginal symptoms respond best to estrogen therapy, which can be administered through the mouth or skin or locally via a cream, tablet or ring. Even a low-dose vaginal tablet containing 10 micrograms of estradiol improves symptoms, the report noted.
- Low-dose vaginal treatments are administered daily for a week or two at first, then once or twice a week indefinitely as maintenance therapy.
Because small amounts of estrogen used vaginally can enter general circulation, women who have had hormone-sensitive breast cancer are advised to try nonhormonal remedies first.
Many women experience relief of symptoms with lubricants and moisturizers prepared with water or silicone. Lubricants, applied just before intercourse, can reduce friction and pain caused by dryness. Moisturizers are used routinely to relieve dryness, itching, irritation and pain, and to improve elasticity.
Last year, the Food and Drug Administration approved Osphena (ospemifene) to treat vaginal atrophy related to menopause. The drug, taken orally once a day, is a selective estrogen receptor modulator that has estrogenlike effects in the vagina. But Osphena, too, can promote endometrial growth. It is not recommended for women who have had breast cancer, and it is not intended for long-term use.
I’m Dr. Michael Hunter.
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