Membership Portal

For information on our Concierge Practice, call 703-873-7425 or email us at [email protected]

Membership Portal

For information on our Conierge Practice, call 703-873-7425 or email us at [email protected]

Menopause & Perimenopause

 

Hormonal and Nonhormonal Therapies for Menopause

Following are the most current considerations and therapy recommendations for easing the symptoms of menopause.

Menopause is defined as the final menstrual period, when the ovaries stop producing follicles that contain eggs and it is no longer possible to get pregnant. Most women experience menopause between ages 40 and 58 (average age is 51). It does not occur suddenly but over a period of 4 to 8 years in the transition phase called perimenopause. Menopause is considered complete 12 months after the final period occurs.

Menopausal and perimenopausal symptoms can commonly include vasomotor symptoms such as hot flashes and night sweats, mood changes, sleep problems, and vaginal dryness; and for some, dry eyes, and increased anxiety and depression. A number of hormonal and non-hormonal therapies are available to alleviate discomfort.

Hormone Therapy (HT) is intended to relieve the bothersome symptoms of menopause, not to replace the amounts produced before menopause. HT consists of estrogen for symptom relief, and progestin to protect the uterine lining. Taking estrogen alone can cause the lining of the uterus to overgrow and potentially lead to uterine cancer. Females who no longer have a uterus due to a hysterectomy are treated with estrogen alone.

Estrogen therapy options

For hot flashes:

  • Estradiol is preferred, identical to the estrogen made by ovaries throughout reproductive life. The standard dose for an estradiol oral pill is 1 mg daily; lower doses such as 0.5 mg seem to cause fewer side effects, such as breast tenderness, nausea and irregular bleeding.
  • Many experts now recommend the estradiol transdermal patch (worn on the skin) rather than pills because it works as well to increase bone density and treat menopausal symptoms, and is associated with a lower risk of blood clots. Patches are changed once or twice weekly. Females with a uterus who use an estrogen patch must also take progestin to decrease the risk of uterine cancer, or use a combination estrogen-progestin patch.
  • Very low-dose birth control pills. These are a good option for females in their 40s who have hot flashes, irregular bleeding, and sell need a reliable form of birth control. Caution is advised for females over 40 who are also obese (higher risk of blood clots) or have hypertension (increased risk of stroke). Not recommended for postmenopausal females, because the dose of estrogen is higher than needed to relieve hot flashes.
  • A “ring” or tablet that is inserted into the vagina, and changed every 3 months.
  • Creams, gels and sprays that can be put on the skin.

For vaginal dryness:

  • Very low doses of vaginal estrogen in cream, ring or tablet form can be used to treat vaginal dryness, vaginal burning and frequent urinary tract infections caused by menopause. These low-dose vaginal estrogens do not require the use of a progestin pill, and because very little goes into blood circulation, is considered a lower risk therapy that can be taken at any age.

Progestin therapy options

  • Oral progesti Commonly prescribed micronized natural progesterone pills have no effect on lipids, and are a good choice for females with high cholesterol levels. Synthetic options include medroxyprogesterone acetate, norethindrone and norgestrel.
  • Intrauterine progesti One type of intrauterine device (the levonorgestrel IUD) used for birth control releases progestin to prevent pregnancy. This is not currently approved in the United States for use in menopausal females; however, if you already have one when you enter perimenopause your doctor may suggest keeping it in until menopause is complete.

Compounded bioidentical hormones

  • Available in pills, creams or vaginal suppositories, the hormones used are identical in molecular structure to those produced by the ovaries. While they are custom-
  • compounded in pharmacies, allowing for individualized doses and mixtures, this may result in reduced efficacy or greater risk. The compounds are not approved or regulated by the US Food and Drug Administration (FDA) because individually mixed recipes are not tested to verify that the right amount of hormone is absorbed to provide predictable hormone levels in blood and i For these reasons, expert groups caution against using them.
  • Another option to consider is the FDA-approved, non-compounded bioidentical estrogen-progestin pill Bijuva, available since 2019. Side effects such as weight gain or hair loss have not been reported.

Benefits of hormone therapy (HT)

  • Effective for hot flashes and night sweats. If these are severe and disrupt daily activities and sleep, HT may improve fatigue and sleep, mood, ability to concentrate and overall quality of life. If symptoms are mild and can be treated non-medically (e.g. layered bedding, light nightclothes in wicking materials, frozen cold pack under pillow) HT may not be needed.
  • Treats vaginal dryness and painful sex associated with menopause.
  • Lowers risk of developing Type 2 diabetes.
  • Some studies show that estrogen treatment helps improve mood and decrease depression; however, some females need both estrogen and an antidepressant to feel better. Note that once females are post-menopausal and hormones stabilize, symptoms usually abate.
  • Preserves bone density, decreases risk of osteoporosis and fractures. However, if other menopause symptoms are not bothersome, HT is not recommended to prevent or treat osteoporosis as other effective medicines (bisphosphonates or denosumab) are available with fewer serious risks.

Risks of hormone therapy (HT)

  • Heart disease. The Women’s Health Initiative (WHI), a large study designed to evaluate the impact of HT, found that taking estrogen-progestin in combination increases the risk of heart attacks, breast cancer, blood clots, and strokes in older postmenopausal females but not in younger postmenopausal females (ages 50 to 59) or in females who become menopausal less than 10 years before starting HT. The estrogen-only study showed a decreased risk of breast cancer, and a small increase in the risk of stroke and blood clots, but no increased risk of heart attacks. These findings have been confirmed in other studies conducted after the WHI.
  • Breast cancer. Typical use of menopausal HT does not appreciably increase the risk of breast cancer. In the WHI, the excess risk was very low in young menopausal females taking combined therapy, and there was a reduced risk for those taking estrogen alone.
  • Dementi Among the older females studied in the WHI, there was no improvement in memory or thinking with either estrogen alone or with combined estrogen-progestin; however an increased risk of developing dementia was seen in older females who started hormones at a late age. No increase in dementia risk was seen in younger menopausal females. Although not yet proven, some experts believe estrogen treatment might be helpful for preventing dementia if taken in the earliest years after menopause; taking it many years after menopause appears to be harmful.

Who should take hormone therapy (HT)? Individualization is key in the decision to use HT and a woman’s quality of life priorities and personal risk factors should be considered. Most experts agree that HT is an acceptable option for relatively young (up to age 59 or within 10 years of menopause) and healthy women who are bothered by moderate to severe menopausal symptoms such as hot flashes. To minimize risk, HT is recommended at the lowest effective dose for the shortest time period.

HT is not recommended for females with a current or past history of breast cancer, coronary heart disease, a previous blood clot, heart atack or stroke, or is at high risk for these issues.  Caution is advised for women with active liver disease, vaginal bleeding or migraine.

Length of hormone therapy (HT). There is not one right time to discontinue HT, but many experts recommend stopping after 4-5 years to avoid any increased risk of breast cancer. Because hot flashes occur on average for 7-8 years, however, it may be advisable to slowly decrease the dose of HT over months or years to reduce the chances of symptoms coming back.

If menopausal symptoms return, nonhormone therapy can be tried or HT resumed, based on individual risk/benefit profile.

Nonhormone therapy

For women who cannot or choose not to use HT, nonhormone options to relieve vasomotor symptoms (hot flashes and night sweats) include:

  • Clinical hypnosis, a mind-body therapy that involves a deeply relaxed state and
  • individualized mental imagery and suggesti
  • Cognitive-behavioral therapy, a form of biofeedback that includes training in relaxation and paced breathing.
  • Weight loss has been shown to reduce vasomotor symptoms in women with obesity.
  • Certain prescription medications, including low-dose oxybutynin (used to treat overactive bladder), fezolinetant (a neurokin B antagonist that works in the brain), gabapentin (used to treat seizures or nerve pain), clonidine (used to treat high blood pressure), low doses of SSRIs/SNRIs (antidepressants), and stellate ganglion block (anesthetic used to treat pain).

Sources: UpToDate, the Menopause Society, The 2023 Practitioner’s Toolkit for Managing Menopause