Written by Dr. Teng
Menopause is a natural transition that occurs when a woman’s ovarian function slows down, resulting in decreased estrogen production. As ovarian activity declines, women may experience hot flushes, night sweats, mood swings, and vaginal dryness due to rapid oocyte depletion and hypoestrogenism. This menopausal transition, also known as perimenopause, has variable duration from one woman to another and leads to changes in the menstrual cycle. Menopause is defined by the absence of menstrual cycles for 1 year, and occurs at an average age of 51. The peak of vasomotor symptoms, which include the hot flushes and night sweats, usually occurs 1 year after the last menstrual cycle and can persist for 10 or more years. They can interfere with sleep and significantly impact a woman’s quality of life.
What did people in ancient times do? How did they survive this horrid period of moodiness, vaginal dryness, sweatiness, and perpetual hot flushes? Maybe it helped women to survive the ice age, but we can call ourselves lucky to be living in modern times, where we can treat and manage these symptoms associated with menopause. We all know that treatment in the form of hormone replacement is an option, and multiple studies support the use of hormone therapy for treatment of severe hot flushes and night sweats. However, there are risks associated with hormone replacement and many women are interested in the non-medical treatments, such as complementary botanicals, natural products, and acupuncture.
So do these natural products and alternative techniques work? Are they even worth trying?
Phytoestrogens are plant-derived substances that have estrogenic biologic activity. Examples include isoflavones found in soy products and red clover. A 2010 meta-analysis of 30 placebo-controlled trials failed to show any benefit of phytoestrogens over placebo in reducing vasomotor symptoms. Many women claim that herbal remedies, including black cohosh, gingko biloba, and dong quai, have improved their hot flashes. However, there are no large, randomized studies showing benefit of these products over a placebo on improving hot flashes. Data is limited and potential adverse effects exist. It is also important to note that herbal supplements are not closely regulated like prescription drugs, and the amount and quality of herbal product may vary from one pill to another. The Dietary Supplement Health and Education Act of 1994 classifies most botanical medicines as food supplements and removes them from regulatory oversight and scrutiny by the FDA.
Regarding acupuncture, a recent systematic review published in the February 2015 issue of the journal Menopause included 12 studies and almost 900 participants. It found that acupuncture significantly reduced the frequency and severity of hot flashes for up to 3 months after treatment in women experiencing natural menopause, and improved overall quality of life. This shows that acupuncture can be an effective, alternative option for women seeking non-pharmacologic therapy.
Are there non-hormonal medications that can help?
Certain antidepressant agents such as selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) have been proven to be effective in treating vasomotor symptoms. An SSRI might be the second choice medication for treatment of severe vasomotor symptoms in women who cannot take hormone replacement. Clonidine and Gabapentin are two other agents that have been successfully used to treat vasomotor symptoms and serve as reasonable alternatives to traditional hormone therapy.
What about bioidentical hormones?
Bioidentical hormones are plant-derived hormones that have a similar chemical structure to those produced in the body. They include commercially available products approved by the FDA, such as micronized estrogen and progesterone, as well as compounded preparations. Compounding is the creation of an individualized preparation based on a health care provider’s prescription, and is performed by compounding pharmacies. A lot of direct-to-consumer marketing and media promotion of compounded bioidenticals as safe and effective alternatives to conventional hormone therapy have led to increasing popularity and questions about its use. Many compounding pharmacies use the term bioidentical to imply that these preparations are natural, and thus safe. The phrase “bioidentical hormone therapy” has been recognized by the FDA and the Endocrine Society as a marketing term, and not one based on scientific evidence. Since the FDA does not regulate these products, the preparations do not undergo testing for purity, quality, and efficacy. There is the benefit of dosage flexibility and lower cost to compounded biodenticals, however that comes with a lack of evidence for its effectiveness and a lack of proper labeling of contraindications and warnings. The potential for underdosage and overdosage also exists. Overall, committees from the American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine have concluded that evidence is lacking to support use of bioidentical hormones over conventional hormonal therapy for menopause. I would advise patients to take caution when considering customized compounded hormones due to the risks of variable purity, bioavailability, and lack of efficacy and safety data.
A recommendation that is constant to almost all medical problems is lifestyle change. Alcohol and caffeine intake have been associated with increased severity and frequency of vasomotor symptoms. Improving one’s lifestyle with stress-reduction, healthy diet, exercise, and relaxation techniques can improve overall quality of life and decrease mood swings associated with menopause. Finding support during this time is helpful.
As women, menopause is a life transition that we will all experience, each in our own unique way. I encourage patients to ask their friends and family about their experiences. The North American Menopause Society has a wonderful website that has great tips, advice, and encouragement about how to make it a positive experience. Several hospitals and health organizations offer seminars on menopause education. For those that experience severe vasomotor symptoms, it is important to understand the safety and efficacy of products that are offered, and to discuss with your doctor options that are optimal for you.
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