Menopause management: How you can do better

The only contraindication to topical estrogen use is allergy to an ingredient in the preparation. Because of its limited systemic absorption and low doses, it can be prescribed for virtually any woman with vaginal symptoms, including those who would not be candidates for systemic therapy. That said, few studies have addressed the use of local estrogens by women with a history of breast cancer. While it is likely a safe option for treatment of atrophic vaginitis, more research involving breast cancer survivors is needed.⁴³

Dehydroepiandrosterone (DHEA) may provide the same benefits as local estrogens, but without any systemic effects.⁴³

Water-soluble lubricants and moisturizers provide short-term relief.⁴³ A variety of over-the-counter (OTC) lubricants are effective at alleviating dyspareunia. However, moisturizers often have limited long-term benefit and may have adverse effects. A hypersensitivity reaction to components of specific formulations is one potential adverse effect. Women need to be aware that some OTC lubricants may damage condoms, as well. (Pregnancy may still be possible for women who have occasional menstrual cycles; condoms also provide protection from sexually transmitted infection.)

Vitamin E, taken orally (100-600 IU/d) or used as a topical preparation, has also been shown to improve symptoms of vaginal dryness.⁴⁶ Early studies of vitamin D in cell culture have shown benefit to atrophic tissues, although limited clinical studies have been performed.⁴⁷

Soy, red clover, and black cohosh have been shown to provide some relief of atrophic symptoms.⁴³ However, each of these agents uses estrogenic pathways, which may be a concern for some patients. Limited safety data and variation in preparations are potential problems, as well.⁴³ Placebo-controlled trials of numerous other herbal products—including bryonia, belladonna, lycopodium, nettle, dong quai root, motherwort, chickweed, and wild yam—have found them to be neither safe nor effective.⁴⁸

Other medications that may have limited use in treating atrophic vaginitis include tibolone, a weak estrogenic steroid, and oral pilocarpine,⁴⁹ but limited data regarding their efficacy and adverse effects curtail their use. Topical lidocaine and oral gabapentin may work as analgesics, but little improvement in tissue integrity can be expected.⁴³

Table 3
Treating atrophic vaginitis^43,45-49

Is intercourse painful? Has she lost interest in sex?
Many menopausal women notice a decline in libido, which is often related to frequent hot flashes or dyspareunia secondary to atrophic vaginitis. In these instances, treatment of the underlying condition, as detailed earlier, should be first-line therapy.

Sustained-release bupropion (300 mg/d) has been shown to increase both sexual arousal and satisfaction in women who are not depressed.⁴⁴

Testosterone therapy is another treatment; in some cases, it can be added to an existing HRT regimen to improve libido. However, testosterone supplementation should be offered only after all other causes of low libido have been excluded. It is not recommended for women who are not on HRT, as its safety in this population is unknown. Long-term clinical trials are needed to assess the effectiveness of medications such as phosphodiesterase-5 inhibitors, although early research has shown encouraging results.⁴³

Is her hair thinning?
Up to 26% of women develop thinning hair at the onset of menopause. This is thought to be the result of the relative increase in circulating androgens that occurs as estrogen production decreases.⁵⁰ Spironolactone has been shown to be a safe and effective intervention. Acting as an antiandrogen, spironolactone is thought to restore the balance between estrogen and androgen, thereby halting hair loss—and, in some women, resulting in partial hair regrowth. A variety of doses have been used, but 100 to 200 mg/d is recommended.⁵¹

Topical minoxidil may also be helpful in women with hair loss, but up to one year of treatment may be necessary before effectiveness can be accurately assessed. The US Food and Drug Administration has approved only the 2% minoxidil solution for use in women, although a 5% solution is available and may be more effective.

Adverse effects of minoxidil include facial hypertrichosis over the cheeks and forehead. This is more likely to occur if the 5% solution is used, but may be reversible within 4 months of discontinuing therapy.⁵² Emerging evidence suggests that a combination of topical minoxidil and topical spironolactone may be helpful for women, without the adverse effects associated with systemic therapy.