Hormone Therapy and Other Treatments for Symptoms of Menopause

 

The results of large clinical trials have led physicians and patients to question the safety of hormone therapy for menopause. In the past, physicians prescribed hormone therapy to improve overall health and prevent cardiac disease, as well as for symptoms of menopause. Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer when used for more than three to five years. Therefore, in women with a uterus, it is recommended that physicians prescribe combination therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration. Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives. Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of endometrial cancer. Women who cannot tolerate adverse effects of progestogens may benefit from a combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene. There is no high-quality, consistent evidence that yoga, paced respiration, acupuncture, exercise, stress reduction, relaxation therapy, and alternative therapies such as black cohosh, botanical products, omega-3 fatty acid supplements, and dietary Chinese herbs benefit patients more than placebo. One systematic review suggests modest improvement in hot flashes and vaginal dryness with soy products, and small studies suggest that clinical hypnosis significantly reduces hot flashes. Patients with genitourinary syndrome of menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved by the U.S. Food and Drug Administration for dyspareunia due to menopausal atrophy). The decision to use hormone therapy depends on clinical presentation, a thorough evaluation of the risks and benefits, and an informed discussion with the patient.

Menopause is the physiologic transition when the ovaries stop releasing eggs, ovarian function decreases, and menstrual periods stop. Although some women go through the menopausal transition without symptoms, many women have hot flashes or genital tract symptoms, such as vulvar or vaginal dryness, painful intercourse, and urinary problems. When counseling patients who are going through menopause, clinicians should understand the benefits and risks of hormone therapy, nonhormonal prescription medications, and alternative treatments, and be familiar with the various delivery methods.

WHAT IS NEW ON THIS TOPIC: TREATMENTS FOR MENOPAUSAL SYMPTOMS

After a median of 13 years of follow-up, women taking combined estrogen/progestogen therapy in the Women's Health Initiative trial had a significantly increased risk of breast cancer and venous thromboembolism, and a reduction in hip fractures.

In 2014, a consensus conference endorsed new terminology: the term genitourinary syndrome of menopause replaces the terms vulvovaginal atrophy and atrophic vaginitis. This is partly because older terminology does not encompass the extent of genital tract symptoms that many women experience.

There is no evidence that using low-dose vaginal estrogen increases the risk of breast cancer recurrence.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer after three to five years of use.

B

3

Systemic estrogen, alone or in combination with a progestogen, is the most effective therapy for menopausal hot flashes, and is approved by the U.S. Food and Drug Administration for this indication.

A

9

Because of the potential risks with long-term use of hormone therapy, clinicians should prescribe the lowest effective dosage for the shortest duration necessary to improve symptoms.

C

8, 12

There is no high-quality, consistent evidence that black cohosh, botanical products, omega-3 fatty acid supplements, or lifestyle modification alleviates hot flashes.

B

1921

The decision to continue combined hormone therapy for more than three to five years should be made after reviewing the risks, benefits, and symptoms with the patient.

C

12

Effective nonhormonal therapies for genitourinary syndrome of menopause include vaginal moisturizers and oral ospemifene (Osphena).

B

31, 32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer after three to five years of use.

B

3

Systemic estrogen, alone or in comb

The Authors

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D. ASHLEY HILL, MD, is chair of the Department of Obstetrics and Gynecology at the Florida Hospital Graduate Medical Education Program in Orlando, and is professor of obstetrics and gynecology at the University of Central Florida College of Medicine in Orlando....

MARK CRIDER, MD, is assistant professor of obstetrics and gynecology at the University of Central Florida College of Medicine, and is medical director of the Labor and Delivery Unit at the Florida Hospital for Women in Orlando.

SUSAN R. HILL, MD, is an internal medicine physician in private practice in Orlando.

Address correspondence to D. Ashley Hill, MD, Florida Hospital Graduate Medical Education, 235 East Princeton St., #200, Orlando, FL 32804 (e-mail: d.ashley.hill.md@flhosp.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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