Menopause medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Rahmah Al-Edresi, M.D.[2]

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 provides the best relief, but hormone therapy should only be used for a short duration and the lowest effective dose, as it increases the relative risk of uterine cancer, ovarian 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

Hormonal replacement therapy(HRT)

• The most effective treatment of severe menopausal symptoms is hormonal replacement therapy (TRH), it used to treat vasomotor symptoms, osteoporosis, prevent genitourinary atrophy and sleep disturbances. The HRT includes estrogens, progesterone and other hormones that are administered to compensate for hormone deficiency in a menopausal woman's body.
• There are several types of therapies such as combined oral contraceptives, systemic estrogen, estrogen-bazedoxifene, estrogen-progestin, progestin alone, and conjugated equine estrogens(Premarin). It is should be used for a short duration and the lowest effective dose and can be given in various forms (tablets, creams, patches), in different modalities (continuous or cyclic).

Selective Estrogen Receptor Modulators (SERMs)

• Selective estrogen receptor modulators(SERMs), such as raloxifene, bazedoxifene, and ospemifene have the ability to modulate estrogen action, without stimulating endometrial hyperplasia or increased risk of cancer. SERMs have the same outcome as hormone therapy in the treatment of osteoporosis.
• Raloxifene acts as an estrogen agonist (pro-estrogen) on bone and lipids, and like an estrogen antagonist (anti-estrogen) on uterus and breast. Thus, it is effective in preventing/treating mild osteoporosis and decreasing serum LDL, and vasomotor symptoms, like hot flashes. Ospemifene is a newer drug of SERM, which is effective in treating urogenital symptoms.

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

Adverse effects:

• All hormone replacement therapies probably do carry some health risks, including high blood pressure, blood clots, and increased risks of breast and uterine cancers. The use of estrogen alone should be avoided in women with having a uterus, it is may cause of uterine hyperplasia and uterine cancer, so the use of combination estrogen-progestin therapy is recommended for women with having a uterus.
• Hormone replacement therapy is contraindicated in women with a positive history of breast cancer, endometrial cancer, deep vein thrombosis, pulmonary embolism, liver disease, dysfunction uterine bleeding, and coronary heart disease due to an increased risk of developing cancer after 3 to 7 years of using hormone therapy.
• 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 use of localized estrogen therapy (vaginal rings, creams, or tablets), has been shown to enhance blood flow and reverse vaginal atrophy and carries a small risk of venous thromboembolism.
• 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 a slightly increased risk of breast cancer, heart disease, stroke, and Alzheimer's disease.
• After these results were reported in 2002, the number of prescriptions written for Premarin 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. And the studies still continue to determine if the drop is related to the reduced use of HRT.

Non Hormonal therapy:

Non hormonal therapy includes serotonin-norepinephrine reuptake inhibitors(SNRIs), selective serotonin reuptake inhibitors (SSRIs), clonidine, and gabapentin.

• SSRIs and SNRIs such as paroxetine (Paxil), Fluoxetine hydrochloride (Prozac), and Venlafaxine hydrochloride (Effexor) are antidepressants that treat vasomotor symptoms, such as hot flashes, improving sleep, mood, and quality of life. These treatments can be used for a few months for menopause symptoms.
• paroxetine (Paxil), in particular, is the only FDA-approved drug for this indication, and symptoms diminish within a week of initiating treatment. 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.
• Both gabapentin and clonidine have been shown to reduce hot flashes in menopausal women. Gabapentin (Neurontin) is an anti-seizure medication, reduces hot flashes by up to 2 hot flashes per day. Clonidine(Catapres) is a blood pressure medicine, this drug may have special consideration for women suffering from high blood pressure and hot flashes. It has most effective in mild hot flashes, but it is less effective than SSRIs/SNRIs and gabapentin.

Complementary and alternative therapies:

• Medical non-hormone treatments are less effective for the relief of symptoms than hormone treatments but it has fewer side effects.
• The complementary and alternative therapies include acupuncture treatment are promising. Some studies indicating positive effects, especially on hot flashes but also others showing no positive effects of acupuncture regarding menopause.
• There are claims that soy isoflavones are beneficial concerning menopause. However, a study indicated that soy isoflavones do 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 and lubricants, such as K-Y Jelly or Astroglide can help women with thinning vaginal tissue, dryness, and decrease the pain 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.
• Drinking cold liquids and removing excess clothing layers when hot flashes strike, and avoiding hot flash triggers such as spicy foods maybe relieve some symptoms for some women.