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What menopause treatment options are there?

While menopause is a natural stage of life, some symptoms may be alleviated through medical treatments. Hormone Replacement Therapy (HRT) is one of the best menopause treatments, but certain forms appear to pose significant health risks. Some drugs afford limited relief from menopausal hot flashes. A woman and her doctor should carefully review her symptoms and relative risk before determining whether the benefits of HRT or other treatments outweigh the risks. Until more becomes known, women who elect to use hormone replacement therapy are generally well advised to take the lowest effective dose of HRT for the shortest period possible, and to investigate whether certain forms may pose fewer dangers of clots or cancer than others may.

Hormone therapy

Estrogen and progesterone therapy

Hormone therapy (HT) , also referred to as hormone replacement therapy (HRT) or postmenopausal hormone therapy (PHT), commonly used to treat menopause symptoms, consists of estrogens or a combination of estrogens and progesterone (progestin). Hormone therapy has been used in the treatment of menopause symptoms such as declining estrogen levels, hot flashes and vaginal dryness, and HT is still the most effective way to treat these symptoms. But long-term studies (the NIH-sponsored Women's Health Initiative, or WHI) of women receiving combined hormone therapy with both estrogen and progesterone were halted when it was discovered that these women had an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. Later studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer. Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus) in postmenopausal women who have not had their uterus surgically removed.

The decision about hormone therapy, therefore, is a very individual decision in which the patient and doctor must take into account the inherent risks and benefits of the treatment along with each woman's own medical history. It is currently recommended that if hormone therapy is used, it should be used at the smallest effective dose for the shortest possible time. The WHI study findings do not support the use of HT for the prevention of chronic disease.

Oral contraceptive pills

Oral contraceptive pills are another form of hormone therapy often prescribed for women in perimenopause to treat irregular vaginal bleeding. Prior to treatment, a doctor must exclude other causes of erratic vaginal bleeding. Women in the menopausal transition tend to have considerable breakthrough bleeding when given estrogen therapy. Therefore, oral contraceptives are often given to women in menopause transition to regulate menstrual periods, relieve hot flashes, as well as to provide contraception. The list of contraindications for oral contraceptives in women going through the menopause transition is the same as that for premenopausal women.

Local (vaginal) hormone menopause treatments

There are also local (meaning vaginal) hormonal treatments for the symptoms of vaginal estrogen deficiency. Local treatments include the vaginal estrogen ring, vaginal estrogen cream, or vaginal estrogen tablets. Local and oral estrogen treatments are sometimes combined for this purpose.

Other pharmaceutical therapies

Antidepressant medications: The class of drugs known as selective serotonin reuptake inhibitors (SSRIs) and related medications have been shown to be effective in controlling the symptoms of hot flashes in up to 60% of women. Specifically, venlafaxine (Effexor), a drug related to the SSRIs, and the SSRIs fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa) have all been shown to decrease the severity of hot flashes in some women. However, antidepressant medications may be associated with side effects, including decreased libido or sexual dysfunction.

Other medications: Other prescription medications have been shown to provide some relief for hot flashes, although their specific purpose is not the treatment of menopausal hot flushes. All of these may have side effects, and their use should be discussed with and monitored by a doctor. Some of these medications that have been shown to help relieve hot flashes include the antiseizure drug gabapentin (Neurontin) and clonidine, a drug used to treat high blood pressure.

Alternative medical therapies

It should be noted that medical non-hormone treatments provide less than complete relief, and each has side effects.

Plant estrogens (phytoestrogens, isoflavones)

Isoflavones are chemical compounds found in soy and other plants that are phytoestrogens, or plant-derived estrogens. They have a chemical structure that is similar to the estrogens naturally produced by the body, but their effectiveness as an estrogen has been estimated to be much lower than true estrogens. Their estrogen potency has been estimated to be only 1/1000 to 1/100,000 of that of estradiol, a natural estrogen.

Two types of isoflavones, genistein and daidzein, are found in soy beans, chick peas, and lentils, and are considered to be the most potent estrogens of the phytoestrogens.

Some studies have shown that these compounds may help relieve hot flushes and other symptoms of menopause. In particular, women who have had breast cancer and do not want to take hormone therapy (HT) with estrogen sometimes use soy products for relief of menopausal symptoms. However, some phytoestrogens can actually have anti-estrogenic properties in certain situations, and the overall risks of these preparations have not yet been determined. For example, researchers have shown that long-term use of phytoestrogens in postmenopausal women led to an overgrowth of the tissues lining the uterus (endometrial hyperplasia) which can be a precursor to cancer.

There is also a perception among many women that plant estrogens are "natural" and therefore safer than HT, but this has never been proven scientifically. Further research is needed to fully characterize the safety and potential risks of phytoestrogens.

Vitamin E

Some women report that vitamin E supplements can provide relief from mild hot flushes, but scientific studies are lacking to prove the effectiveness of vitamin E in relieving symptoms of menopause. Taking a dosage greater than 400 international units (IU) of vitamin E may not be safe, since some studies have suggested that greater dosages may be associated with cardiovascular disease risk.

Black Cohosh

Black cohosh is an herbal preparation that has been popular in Europe for the relief of hot flashes. However, there have still been very few scientific studies done to establish the benefits and safety of this product. Research is ongoing to further determine the effectiveness and safety of black cohosh.

Other alternative therapies

There are many supplements and substances that have been advertised as "natural" treatments for symptoms of menopause, including licorice, dong quai, chasteberry, and wild yam. Scientific studies to prove the safety and effectiveness of these products have not been performed.

Non-pharmaceutical therapies

In women for whom oral or vaginal estrogens are deemed inappropriate, such as breast cancer survivors, or women who do not wish to take oral or vaginal estrogen, there are varieties of over-the-counter vaginal lubricants. However, they are probably not as effective in relieving vaginal symptoms as replacing the estrogen deficiency with oral or local estrogen.

Obvious measures, such as drinking cold liquids and removing excess clothing layers when menopausal hot flashes strike, and avoiding hot flash triggers such as spicy foods, may supplement or supplant the use of medications for some women.