Menopause

Hormone replacement therapy and other treatments

Contrary to what some women may believe, menopause itself does not require any form of medical treatment. Rather, it is the signs and symptoms of menopause—in particular, hot flashes—that may require treatment. In addition, treatments may also be necessary to prevent or lessen other conditions such as heart disease and osteoporosis that may arise during the years after menopause.

Hormone therapy

Hormone therapy, often used in the treatment of hot flashes, consists of low doses of estrogen, often in combination with progestin. Hormone therapy, available in a variety of forms including pills, patches, creams, and vaginal rings, has also proven effective in the treatment of other menopausal symptoms such as vaginal dryness and difficulty during intercourse. It should be noted that hormone therapy is tailored to each woman to meet her individual needs.¹

Estrogen replacement therapy, or ERT, is often recommended for women who have had a hysterectomy. These women take estrogen alone, while most other women who take HRT are advised to take estrogen in combination with progestin, because progestin helps protect against uterine cancer>. Hormone therapy taken as estrogen alone or as a combination therapy also provides other health benefits: it helps protect against bone loss and osteoporosis. What's more, oral hormone therapy has been shown to raise levels of good cholesterol (high-density lipoprotein or HDL) while reducing levels of bad cholesterol (low-density lipoprotein or LDL).²

The risks of hormone therapy

While women may derive certain benefits from hormone therapy, they should note there are also risks associated with this form of treatment. Hormone therapy as a combination therapy—that is, estrogen plus progestin—can have serious side effects and health risks which should be discussed with your doctor.

Consider:

In July 2002, a large, multitiered clinical trial sponsored by the National Institutes of Health reported that, for most women, the risks of hormone therapy actually outweighed its benefits. The study found that women taking combination estrogen-progestin (Pempro) were at increased risk of heart disease, breast cancer, stroke, blood clots, and dementia. Not only did hormone therapy increase women's risk of breast cancer, the study further revealed that such treatment also made tumors more difficult to detect, thereby leading to delays—potentially dangerous ones—in diagnosis.³

Preliminary results also indicated that while women taking only estrogen (Premarin) showed no increased risk of breast cancer or heart disease and no reduction in the risk for dementia and mild cognitive impairment, they did show a slightly increased risk of stroke. If anything, the data showed a trend toward the development of cognitive impairment. As a result, hormone therapy is no longer recommended as a means to prevent dementia in women over the age of 65.⁴

Finally, based on accumulated study results, it appears combination hormone therapy does not provide meaningful improvement in terms of sleep, emotional health, general health, physical functioning, and sexual satisfaction.⁵

As the number of health risks associated with hormone therapy grew, more and more doctors concurred that hormone therapy does not appear to be the therapy of choice for disease prevention in older women and as such, have discontinued prescribing hormone therapy in favor of alternative, non-hormonal treatments.

Who can benefit from hormone therapy?

While it is true that some women can experience relief of menopausal symptoms, in addition to decreased risk of osteoporosis-related hip fractures and of colorectal cancer, it's best to talk with your doctor about your personal risks. Such a discussion will help your doctor determine whether hormone therapy is right for you. It may well be a viable treatment for you if you have hot flashes, night sweats, vaginal discomfort (including dryness, itching, and burning), or osteoporosis.⁶

Your doctor may recommend that you decrease your dose of estrogen or that you switch from one from of hormone therapy to another—from a pill to a patch, for instance. If you are prescribed hormone therapy, take the lowest effective dose for the shortest possible time as needed to treat your symptoms.

Who should avoid hormone therapy?

Hormone therapy may not be advisable if you have a history of breast cancer; as explained, hormone therapy may increase your risk of this disease. In addition to lifestyle modifications, there are non-hormonal alternatives to hormone therapy, all of which can help deal with bothersome symptoms.⁷

Alternatives to hormone therapy

Bisphosphonates

Bisphosphonates, which may include alendronate (Fosamax) and risedronate (Actonel) are often prescribed to prevent or treat osteoporosis. Although they don't provide the same level of protection estrogen does, these medications nevertheless reduce both bone loss and the risk of fractures. Side effects of aldendronate may include gastrointestinal problems/intolerance, esophageal ulcers, and irritation of the esophagus (esophagitis). These side effects increase if medication is not taken as prescribed or if a woman has had reflux or ulcers in the past. Taking a dose intravenously may be an alternative if taking the drug in pill form isn't possible.⁸

Selective estrogen receptor modulators (SERMs)

SERMs, or selective estrogen receptor modulators, are among a group that includes raloxifene (Evista). By mimicking the actions of the body's hormones, raloxifene has some of the benefits of estrogen, namely improved bone strength and reduced risk of fractures in the spine. Unlike hormone therapy, however, raloxifene doesn't stimulate breast or uterine tissue, and therefore, it doesn't cause breast tenderness or uterine bleeding. What's more, raloxifine doesn't carry the risk of breast cancer associated with hormone therapy. In fact, early studies suggest that raloxifene may actually decrease the risk of breast cancer. In spite of these benefits, however, raloxifene tends to exacerbate, rather than relieve, hot flashes. It also carries the risk of blood clots and gallstones.⁹

Teriparatide

A parathyroid hormone, teriparatide (Forteo) is a powerful drug used to treat osteoporosis in post-menopausal women at high risk of fractures. It is injected once daily into the thigh or abdomen. Teriparatide differs from other available therapies for osteoporosis in that instead of preventing bone loss, it stimulates new bone growth.¹⁰

Calcitonin

Helping maintain bone density, calcitonin may slow bone loss and prevent fractures. Although less effective than bisphosphonates in the treatment of osteoporosis, calcitonin has been shown to provide pain relief in women with painful compression fractures. Typically available as a nasal spray, calcitonin is also available as an injection.¹¹

Antidepressants

Scientific evidence suggests that post-menopausal women taking antidepressants such as Venlafaxine (Effexor XR) in doses lower than those used in the treatment of depression experience a slight reduction in hot flashes. Serotonin reuptake inhibitors (SSRIs)—antidepressants such as paroxetine (Paxil), fluoxetine (Prozac), citalopram (Celexa) and others—also show promise for reducing hot flashes.¹²

Though not as effective as estrogen in the treatment of severe hot flashes, antidepressants do appear to be the treatment of choice for women who cannot or who choose not to take estrogen. It's important to discuss with your doctor whether the benefits outweigh the potential side effects such as nausea, dizziness, or sexual dysfunction.¹³

Gabapentin

Commonly used to treat seizures and pain associated with shingles, gabapentin (Neurontin) is also increasingly used to treat chronic pain and evidence suggests that it is also moderately effective in the treatment of hot flashes; it's now prescribed for menopausal hot flashes when other treatments are ineffective or aren't an option. As with some antidepressants, side effects may include drowsiness, dizziness, and nausea.¹³

Clonidine

A pill commonly used to treat high blood pressure, clonidine can significantly reduce the frequency of hot flashes, although the drug does carry undesirable side effects including dizziness, drowsiness, dry mouth and constipation.¹⁴

Alternative (dietary and herbal) treatments

In addition to non-hormonal medications, a number of herbal and dietary supplements including soy, black cohosh, wild yams, evening primrose, and chasteberry are often touted as effective remedies for hot flashes. (See Hot Flashes for more information on these.)

The table below outlines the effectiveness of various remedies.

Agent	Hot Flash Reduction
Estrogen	50%–100%
Progestin	71%–90%
Soy	35%–45%
Black cohosh	27%–28%
Vitamin E	25%
Clonidine	37%–41%
Serotonin drugs* * Refers to selective serotonin uptake inhibitors such as fluoxetine (Prozac®) and sertraline (Zoloft®)	34%–65%

Source: Hot Flashes - What Can be Done? Health and Age. (2004)

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