Hormone Therapy and Other Treatments for Symptoms of Menopause
Am Fam Physician. 2016 Dec 1;94(11):884-889.
Patient information: See related handout on treating menopausal symptoms, written by the authors of this article.
Author disclosure: No relevant financial affiliations.
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.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer after three to five years of use.
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.
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.
There is no high-quality, consistent evidence that black cohosh, botanical products, omega-3 fatty acid supplements, or lifestyle modification alleviates hot flashes.
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.
Effective nonhormonal therapies for genitourinary syndrome of menopause include vaginal moisturizers and oral ospemifene (Osphena).
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 recommendation||Evidence rating||References|
Combined estrogen/progestogen therapy, but not estrogen alone, increases the
REFERENCESshow all references
1. Rossouw JE, Anderson GL, Prentice RL, et al.; Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321–333....
2. Anderson GL, Limacher M, Assaf AR, et al.; Women's Health Initiative Steering Committee. Effects of conjugated equine estrogen in post-menopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004;291(14):1701–1712.
3. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013;310(13):1353–1368.
4. Mikkola TS, Clarkson TB. Estrogen replacement therapy, atherosclerosis, and vascular function. Cardiovasc Res. 2002;53(3):605–619.
5. ACOG committee opinion no. 565. Hormone therapy and heart disease. Obstet Gynecol. 2013;121(6):1407–1410.
6. The American Academy of Family Physicians. Hormone replacement therapy. http://www.aafp.org/patient-care/clinical-recommendations/all/hrt.html. Accessed December 1, 2016.
7. Gold EB, Colvin A, Avis N, et al. Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition. Am J Public Health. 2006;96(7):1226–1235.
8. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause. 2012;19(3):257–271.
9. Maclennan AH, Broadbent JL, Lester S, Moore V. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database Syst Rev. 2004;(4):CD002978.
10. Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015;22(11):1155–1172.
11. Mohammed K, Abu Dabrh AM, Benkhadra K, et al. Oral vs transdermal estrogen therapy and vascular events: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100(11):4012–4020.
12. ACOG practice bulletin no. 141. Management of menopausal symptoms. Obstet Gynecol. 2014;123(1):202–216.
13. Jaakkola S, Lyytinen H, Pukkala E, Ylikorkala O. Endometrial cancer in postmenopausal women using estradiol-progestin therapy. Obstet Gynecol. 2009;114(6):1197–1204.
14. Goletiani NV, Keith DR, Gorsky SJ. Progesterone: review of safety for clinical studies. Exp Clin Psychopharmacol. 2007;15(5):427–444.
15. Pickar JH, Yeh IT, Bachmann G, Speroff L. Endometrial effects of a tissue selective estrogen complex containing bazedoxifene/conjugated estrogens as a menopausal therapy. Fertil Steril. 2009;92(3):1018–1024.
16. Johnson K, Hauck F. Conjugated estrogens/bazedoxifene (Duavee) for menopausal symptoms. Am Fam Physician. 2016;93(4):307–314.
17. Depypere H, Inki P. The levonorgestrel-releasing intrauterine system for endometrial protection during estrogen replacement therapy: a clinical review. Climacteric. 2015;18(4):470–482.
18. Sideras K, Loprinzi CL. Nonhormonal management of hot flashes for women on risk reduction therapy. J Natl Compr Canc Netw. 2010;8(10):1171–1179.
19. Newton KM, et al. Treatment of vasomotor symptoms of menopause with black cohosh, multibotanicals, soy, hormone therapy, or placebo: a randomized trial. Ann Intern Med. 2006;145(12):869–879.
20. Lethaby A, et al. Phytoestrogens for menopausal vasomotor symptoms. Cochrane Database Syst Rev. 2013;(12):CD001395.
21. Cohen LS, Joffe H, Guthrie KA, et al. Efficacy of omega-3 for vasomotor symptoms treatment. Menopause. 2014;21(4):347–354.
22. Franco OH, Chowdhury R, Troup J, et al. Use of plant-based therapies and menopausal symptoms. JAMA. 2016;315(23):2554–2563.
23. Kaunitz AM, Manson JE. Management of menopausal symptoms. Obstet Gynecol. 2015;126(4):859–876.
24. Elkins GR, Fisher WI, Johnson AK, et al. Clinical hypnosis in the treatment of postmenopausal hot flashes. Menopause. 2013;20(3):291–298.
25. Ockene JK, Barad DH, Cochrane BB, et al. Symptom experience after discontinuing use of estrogen plus progestin. JAMA. 2005;294(2):183–193.
26. Castracane VD, et al. When is it safe to switch from oral contraceptives to hormonal replacement therapy? Contraception. 1995;52(6):371–376.
27. Allen RH, Cwiak CA, Kaunitz AM. Contraception in women over 40 years of age. CMAJ. 2013;185(7):565–573.
28. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888–902.
29. Portman DJ, Gass ML. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):1063–1068.
30. Oge T, Hassa H, Aydin Y, Yalcin OT, Colak E. The relationship between urogenital symptoms and climacteric complaints. Climacteric. 2013;16(6):646–652.
31. Bygdeman M, Swahn ML. Replens versus dienoestrol cream in the symptomatic treatment of vaginal atrophy in postmenopausal women. Maturitas. 1996;23(3):259–263.
32. Bachmann GA, Komi JO. Ospemifene effectively treats vulvovaginal atrophy in postmenopausal women. Menopause. 2010;17(3):480–486.
33. Rahn DD, et al. Vaginal estrogen for genitourinary syndrome of menopause: a systematic review. Obstet Gynecol. 2014;124(6):1147–1156.
34. Farrell R; American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice. ACOG committee opinion no. 659. The use of vaginal estrogen in women with a history of estrogen-dependent breast cancer. Obstet Gynecol. 2016;127(3):e93–e96.
35. Hill DA, Hill SR. Counseling patients about hormone therapy and alternatives for menopausal symptoms. Am Fam Physician. 2010;82(7):801–807.
36. Carroll DG. Nonhormonal therapies for hot flashes in menopause. Am Fam Physician. 2006;73(3):457–464.
37. Morelli V, Naquin C. Alternative therapies for traditional disease states: menopause. Am Fam Physician. 2002;66(1):129–134.
38. Cutson TM, Meuleman E. Managing menopause. Am Fam Physician. 2000;61(5):1391–1400.
Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions