• Hormone replacement therapy should be considered only for women who are <60 years old and within 10 years of menopause. B
• Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors may reduce the frequency of hot flashes within 1 to 2 weeks of initiating treatment. B
• Local estrogen preparations should be first-line therapy for atrophic vaginitis. B
• Spironolactone may improve menopause-related hair loss. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE During a routine well-woman visit, 54-year-old Barbara P becomes tearful and confides that she’s afraid her marriage of 20 years is falling apart. She and her husband argue frequently, Barbara says, and she alternates between being tearful and angry for no apparent reason. Barbara’s last menstrual period was 2 years ago. When asked about menopausal symptoms, she reports having 6 or 7 hot flashes daily—which disrupt her sleep several nights a week. She also reports that intercourse is painful and that her interest in sex has diminished as a result. A pelvic exam reveals thin, pale vaginal epithelium; the rest of her physical exam is normal.
Many women with menopausal symptoms that significantly impair their quality of life never report them to their physicians—or do so only if they’re asked, as I have discovered in my practice. The mistaken belief that there are few effective treatments for menopausal symptoms, coupled with concern about adverse effects of hormone replacement therapy (HRT), prompts many women to suffer in silence. That’s a problem you can do much to change.
Broaching the subject with perimenopausal women, rather than waiting for them to initiate the discussion, is an important first step. Let them know that common menopausal symptoms, including hot flashes, atrophic vaginitis, insomnia, diminished libido, and hair loss, can be treated successfully with a variety of hormonal and nonhormonal agents. And when a patient reveals, as Barbara did, that she’s troubled by mood swings or uncharacteristic behavior, it may help to let her know that many women find it challenging to deal with both the physical and emotional ramifications of this new phase of life.
Hot flashes: How often? How severe?
Hot flashes are experienced by up to 75% of menopausal women, and tend to be most severe in the first 2 years of menopause.1 There is a broad spectrum of frequency and severity, however, so it’s important to question patients about both. Risk factors for greater severity and higher frequency include surgically or chemically induced menopause, an elevated body mass index, a history of tobacco use, and African American ethnicity.2,3 There are multiple treatments for hot flashes, including HRT, antidepressants, antiepileptics, antihypertensives, acupuncture, herbal remedies, and even physical activity (TABLE 1).4,5
|HRT Estrogen-progesterone combination (estrogen only for women with hysterectomy)|
|Antidepressants* SNRIs SSRIs|
|Antiepileptics Gabapentin (900 mg/d)|
|Antihypertensives Clonidine (0.1 mg/d, then titrate upward)† Methyldopa (200-500 mg once or twice a day)|
|Herbal supplement's Black cohosh‡ Magnesium (400 mg/d) Omega-3 fatty acid‡ Red clover‡ St. John's wort‡|
|Lifestyle/alternative interventions Acupuncture† Avoidance of triggers§ Paced respirations Physical activity Yoga|
|HRT, hormone replacement therapy; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors. |
*Specific antidepressants and dosage are detailed in Table 2.
†Limited data on effect.
‡Optimal dose is unknown.
§Eg, alcohol, hot drinks, spicy foods, and caffeine.
A critical look at HRT
HRT (an estrogen-progesterone combination for women with an intact uterus, and estrogen alone for those who’ve had a hysterectomy) is highly effective, alleviating hot flashes and other menopausal symptoms 80% to 90% of the time.6 But widely publicized reports from the Women’s Health Initiative of an increased risk of breast cancer, coronary heart disease, stroke, and venous thromboembolism in women taking both estrogen and progesterone prompted many patients to taper off HRT, or decline to start it.7,8 That initial report was a decade ago, however, and further analyses and additional research have since found that for some women and under some circumstances, HRT may, in fact, be safe and effective.9
Age and time of menopause are key criteria. For women who are <60 years old and within 10 years of the onset of menopause, HRT appears to be a safe short-term treatment.9 While the risks may be most significant after 10 years of use, physicians should attempt to limit HRT whenever possible.