Manage Menopause With Reassurance, Relief, Reassessment


CALGARY, ALTA. — Reassurance, relief, and reassessment are hallmark factors in providing practical management of menopausal symptoms.

“We need to remind women that menopausal symptoms are normal,” Dr. Cynthia Stuenkel said at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. “For many women, vasomotor symptoms are self-limited. There is a small percentage of women in whom these symptoms go on for a very long period of time. But for most women these symptoms will abate within a number of years.”

Dr. Stuenkel of the division of endocrinology and metabolism at the University of California, San Diego, also emphasized the importance of reassuring women that vaginal symptoms are easy to treat. “I'm surprised that I still encounter women who don't know that there is a whole aisle at their drugstore with vaginal moisturizers and vaginal lubricants, or the fact that we can just use vaginal estrogens,” she commented.

Another key factor in the practical management of menopausal symptoms is providing “relief.” Dr. Stuenkel makes it a point to tell healthy menopausal women that short-term hormone therapy is relatively safe, noting that use of hormone therapy has switched from an emphasis on prevention of heart disease and other disorders to a focus on symptom relief if necessary.

Women opposed to hormone therapy can try alternative strategies for relief of hot flashes, such as lowering their core temperature; getting regular exercise; and avoiding hot flash triggers such as coffee, alcohol, and spicy foods. Nonprescriptive remedies such as soy foods, isoflavones, black cohosh, and vitamin E may work for some women, “though in randomized clinical trials these have not been of particular benefit,” said Dr. Stuenkel, who is a member of the Board of Trustees of the North American Menopause Society.

Clinical trials of paroxetine, fluoxetine, venlafaxine, gabapentin, and clonidine have shown some positive effect on hot flashes. However, the consensus is that for women who are able to take it, hormone therapy most effectively treats vasomotor and vaginal symptoms.

Dr. Stuenkel and other experts advocate initiating hormone therapy at lower doses than those used in the Women's Health Initiative. For example, low-dose forms of oral estrogen found to be effective for treatment of vasomotor symptoms include conjugated equine estrogens 0.3 mg, micronized 17-β-estradiol 0.5 mg, and ethinyl estradiol 2.5 mcg. Low-dose transdermal preparations found to be effective include the 17-β-estradiol patch 25 mcg, cutaneous gel 1–1.25 g, and estrogen lotion (one packet).

Compared with oral preparations of estrogen, Dr. Stuenkel said, transdermal preparations possibly lower levels of venous thromboembolic events, triglycerides, C-reactive protein, and sex hormone-binding globulin.

Another hallmark factor in the practical management of menopausal symptoms is reassessment. “We don't just make a plan and then put these women on autopilot forever,” she said. “Have the symptoms been relieved? With the low-dose therapies it may take longer, and there may not be a complete obliteration of all symptoms, but there should be an improvement.”

If you're giving hormone therapy and symptoms aren't improving at all, “there's a rare woman who may have an absorption problem, but remember to think about other possibilities, such as thyroid disease,” Dr. Stuenkel advised.

How long a woman should remain on hormone therapy remains unclear. The mantra “lowest dose, shortest time” is widely accepted, “but what does that really mean?” Dr. Stuenkel asked. “I'm not sure we really know. The downside to long-term therapy is probably risk of breast cancer, which varies by type of hormone therapy, duration, and timing of exposure.”

Women who quit hormone therapy cold turkey can expect their symptoms to peak at 8–12 weeks, Dr. Stuenkel said. She recommends a tapering schedule by days or by dose.

Dr. Stuenkel had no relevant financial disclosures to make.

The presentation was part of a session sponsored by Bayer HealthCare Pharmaceuticals.

'We don't just make a plan and then put these women on autopilot forever.' DR. STUENKEL

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