Brooke Thai, PharmD Candidate
Welcome back, readers! I see my last article interested you enough to want to read the second one. In the last article, I talked about (peri)menopause and its symptoms. If you can’t remember, you can refresh your memory here. Today, I’ll talk about the treatments that are used to minimize those symptoms.
What Are the Treatment Options?
First of all, some lifestyle tips can be used to help when hot flashes occur:1
- Dress in layers so you can take off/put on layers as needed
- Wear clothes made of breathable fabrics like linen, cotton, chambray, etc.
- Consume cool drinks
- Use a handheld fan
- Avoid known triggers
- Maintain a healthy body weight
- Quit smoking
If you aren’t quite ready to use the hormonal therapies I’m about to explain, you can try using some natural health products or dietary changes.
Black cohosh and red clover extract (Promensil® or menoflavon®) are some natural health products that have shown to help with hot flashes; however, there’s a mix of evidence and may not work for everyone. In terms of dietary changes, you can try consuming more phytoestrogens, which are plant compounds with estrogen-like activity, such as soybeans, soy products, red clover, and flaxseed.1
While these strategies tend to be less effective compared to hormonal therapies,1 they’re always worth a shot if you value trying something more natural-based. As a quick reminder, always consult your healthcare provider for details on the product, the instructions, its safety and potential interactions with your current medications. Also, be aware that it usually takes 8-12 weeks of regular consumption in order to see effect.
Now, let’s take a look at prescription therapy. The most effective treatment for moderate to severe vasomotor symptoms is menopausal hormone therapy (MHT):1
- Estrogen-only products for women who have had a hysterectomy and do not have a uterus
- Both estrogen and progestin for women with an intact uterus
Hormone therapy can come in the form of oral pills or topical patches/gels. If you have certain comorbidities such as diabetes, high blood pressure, obesity, high lipid levels, gallstones, migraines, or if you smoke; topical patches/gels are safer and therefore preferred over the oral form of hormone therapy.2
It’s important to talk to your healthcare provider regarding the safety of MHT use because there are special circumstances where MHT is unsafe and inappropriate to use in certain patients. If this is the case, non-hormonal options are available to manage vasomotor symptoms. Such options with the best evidence are SSRIs/SNRIs (such as venlafaxine, desvenlafaxine, escitalopram and citalopram), gabapentinoids, clonidine, cognitive behaviour therapy, and hypnosis.1,2
For Genitourinary Symptoms
Estrogen therapy in the form of vaginal tablets, creams or rings is strongly recommended, along with non-estrogen water-based or silicone-based vaginal lubricants and moisturizers.1 These can be used in combination with MHT if genitourinary symptoms persist.2 It’s possible to only use vaginal estrogen therapy if a woman is experiencing only vaginal symptoms.
In addition to helping with vasomotor and genitourinary symptoms, MHT can help with bone protection to prevent osteoporosis and fractures, as well as mood, joint pain, sleep, sexuality and overall quality of life.2
Common Concerns with MHT
Breast Cancer Risk
Because there are estrogen receptors in the breast, many people are concerned that using estrogen will significantly increase their risk of breast cancer. Surprisingly, the risk of breast cancer when using MHT (specifically, estrogen and progestin together) has been shown to be only 0.08% per year,3 meaning 8 in 10 000 women may get breast cancer while using MHT, which is classified as a very rare risk. The risk can be further reduced by using lower doses of estrogen.2
For those using estrogen only (i.e., those without a uterus), there was no difference seen in breast cancer risk based on a study that looked at subjects taking estrogen pill for several years versus those taking a sugar pill for the same amount of time.3 If you have first-degree relatives with breast cancer, you should advise your healthcare professional of this before you begin taking MHT. It doesn’t mean you can’t take it, but that you will be more closely monitored than usual. However, if you have breast cancer, you cannot take MHT.
Clots Leading to Pulmonary Embolisms, Deep Vein Thromboses, Heart Attacks, and/or Strokes
The risks of getting a clot resulting with the above-mentioned outcomes are the highest if MHT is initiated in women over 60 years of age. There is no added stroke risk when it is initiated in women under 60 years of age or within 10 years of their last menstrual period. In fact, it seems to help prevent these outcomes when started early enough.3 Nevertheless, due to these risks, low or ultra-low doses of estrogen are preferred when continuing MHT in older women.2 But, if you have any risk factors that increase your chances of clotting, you cannot take MHT.
Around the age of menopause, it’s natural for women to gain about 5-10 lbs per decade. It’s the hormonal changes of menopause that cause this, and MHT can actually help reduce the amount of weight usually gained at this point in life!2
Duration of Therapy
When should hormone therapy be started? How long should one expect to be on hormone therapy?
Initiation of hormone therapy is safest for women under 60 years of age or are less than 10 years past menopause. As for when to discontinue it, it all depends on the symptoms! Approximately 50% of women have their vasomotor symptoms come back when they discontinue their hormone therapy.1 With proper counselling and surveillance, it’s safe to continue on the hormone therapy for as long as it’s needed.2 So, in terms of safety, it doesn’t matter how long someone is taking MHT, it just matters that they start it at the right time.
The Bottom Line
MHT can significantly improve quality of life. The risks of MHT (increased risk of breast cancer, heart disease and stroke, clots in the lungs or legs) have been shown to be very small and occur very rarely. The benefits of MHT include vasomotor and genitourinary symptom relief, prevention of osteoporosis and related fractures, improvement in joint pain and possibly mood and sleep — and these benefits are much more commonly seen than the risks.
As always, we hope you took away something valuable from this piece. If you have any questions or concerns regarding this article or others, feel free to reach out to us on Instagram, Facebook, or at email@example.com with your feedback. We’d love to hear from you.
- Current Perspectives on the use of Menopausal Hormonal Therapy (MHT) – A Guideline and Case-Based Approach to Management. (2018). Presentation by Dr. Nese Yuksel on May 10, 2018, Edmonton, AB.