Treatment Options for Menopausal Symptoms

Menopausal Hormone Therapy and Menopausal Symptoms

Al-Safi ZA, Santoro N
Fertil Steril. 2014;101:905-1015

Background

The ovary has a limited life span. On average, it starts its regular cyclic activity at age 11-12 and ceases its activity around the age of 50.^[1] The ovaries stop working when the follicle pool decreases to a critically small size, and follicles can no longer be recruited. Menopause is preceded by a 5- to 7-year transition period during which the characteristics of the cycles change, hormonal alterations can be detected, and various symptoms typical for this transition period appear.^[1]

Menopause is also characterized by typical hormonal changes, mainly, a reduction in serum estrogen and androgen levels. These hormonal changes are accompanied by obvious and less obvious clinical symptoms. Typical signs of hypoestrogenism include vasomotor symptoms, sleep disturbances, mood changes, vaginal irritation, and dyspareunia due to atrophy. The less obvious changes are increased bone loss, increased risk for cardiovascular disease and cognitive impairment, and higher incidence of various cancers.^[2]

This paper reviews the "obvious" symptoms of perimenopause/menopause and treatment options.

The Review

Vasomotor symptoms, including hot flashes and night sweats, are experienced by the majority of women entering menopause (60%-80%). They're believed to be due to a narrowing of the thermoneutral zone in the hypothalamus; and, therefore, small changes of the core temperature induce compensatory mechanisms. Sleep disturbance is also a common complaint among perimenopausal women; it is often related to vasomotor symptoms.

Estrogen is required to maintain the turgor of the vaginal mucosa. In response to low levels of estrogen, a woman may experience vaginal atrophy with accompanying irritation, itching, sexual discomfort, and urinary problems. There are various treatment options that one can offer to manage the symptoms of hypoestrogenism, but, first, all comorbidities, such as thyroid dysfunction and vaginitis, need to be ruled out.

Lifestyle changes, including smoking cessation, reduced alcohol consumption, layered dressing, and proper diet, may offer some relief. In addition, selective serotonin or norepinephrine reuptake inhibitors may reduce the intensity and severity of hot flashes.^[3]Clonidine and gabapentin are also effective when used to manage vasomotor complaints.^[3]

Estrogen and estrogen-progestin hormone therapy (HT) are, however, the most effective means of symptom relief for the symptomatic menopausal woman.^[3,4] Estrogen is available as oral, transdermal, vaginal, and injectable preparations, while progestin is available as oral, transdermal, intrauterine, and injectable formulas. For those with an intact uterus, estrogen should be combined with progestin for endometrial protection. Vaginal estrogen in low doses may be used alone if vaginal symptoms are the only indication for treatment.

Selective estrogen receptor modulators (SERMs) can also be used to manage vaginal atrophy.^[3] Tissue selective estrogen complex (estrogen + SERM) provides the benefits of estrogen without endometrial stimulation.

Cite this: Peter Kovacs. Treatment Options for Menopausal Symptoms - Medscape - Jul 23, 2014.

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