Treating Menopause without Hormones

Menopause occurs when there is a complete cessation of the menstrual period for 12 consecutive months. This usually takes place between the ages of 50-52 years old but can occur at any age from the mid 40's to the mid 50's. During the menopausal transition, a variety of physiological changes occur that can have a profound impact on women's lives. Menopause is the result of the natural decline in the hormones (estrogen, progesterone) produced in the ovaries. As hormone levels decrease, a number of symptoms may emerge, although their presentation and severity varies greatly from woman to woman.

This month I will focus on hot flashes. Hot flashes typically begin when cycles become irregular. They occur in about 80% of women. They usually end 1-2 years after menstruation has ceased but can continue for 5 years or more. Symptoms range from flushing or warmth in the face and upper body to sweating and chills. Twenty percent of women find them intolerable. For instance, hot flashes can lead to severe sleep disturbances.

What causes hot flashes? They appear to be the result of mixed signals from the hypothalamus. This results in altered thermoregulation although the exact mechanism is unknown. The most thoroughly studied and most effective treatment for hot flashes is hormone replacement therapy. Synthetic hormones (either bio-identical or not) can be given in many forms (either compounded or not) such as pills, patches, creams/lotions, vaginal preparations, etc. (For more information about bio-identical hormones please see the newsletter from February 2007.) As most of you know, there can be serious health risks associated with hormone therapy such as blood clots, heart disease, and breast cancer. But there are many unanswered questions about hormone therapy. We are just beginning to study how the timing of therapy, dosage, type of hormone, hormone delivery method and the woman's individual health issues and genetics interplay and affect health outcomes. We have a lot to learn!

In the meantime, we have studied non-hormonal pharmaceuticals and found that they can also help with hot flashes. These drugs may be of particular interest to women who are not good candidates for hormonal therapy such as women with risk factors for heart disease or breast cancer. There are also many women who would prefer not to take hormones and these drugs may be an option for them as well.

One class of drugs that has been studied is anti-depressants. Paroxetine (Paxil) is an SSRI that was studied in 2 large clinical trials. The studies showed a significant reduction in the frequency of hot flashes. Women taking tamoxifen for breast cancer should check with their oncologist before taking this medication. Side effects include: headache, nausea, dry mouth, loss of appetite and decreased sexual desire.
Venlafaxine (Effexor) is an SNRI, another type of anti-depressant. One large clinical trial showed a decrease in the number of hot flashes and an increased sense of well being. Higher doses may be more effective but can lead to more side effects. Women should be aware that this drug can cause heavy uterine bleeding, galactorrhea (milk from breasts), and mastodynia (tender breasts).

Another class of drugs that has been studied is anti-convulsants. Two studies have found Gabapentin (Neurotin) to be effective for hot flashes. Common side effects include dizziness and sleepiness.

Finally, an anti-hypertensive, Clonidine has been studied in 10 trials. Half of the studies showed a reduction in hot flash frequency and severity. It has mostly been studied among women taking tamoxifen for breast cancer. The most common side effect of this drug is difficulty sleeping.

Some things to keep in mind:

Many of these drugs reduced frequency of hot flashes but not always severity. Two to three fewer hot flashes a day may have been statistically significant in a clinical trial but will it make a difference in a woman's quality of life? Each woman will need to decide this for herself.

None of these drugs have FDA approval for the treatment of hot flashes. So when they are prescribed it is "off label" this may lead to problems with reimbursement from some insurance companies.

Be aware of drug interactions. These drugs may interact with other medications and/or herbs/supplements you may be taking. Always tell your provider about all the drugs and supplements you are taking.

If you need advice about the treatment of hot flashes, please let me know. From a holistic perspective, there are a number of treatments to choose from. In addition, we can discuss herbs/supplements, nutrition, mind/body techniques and physical activity that support your health during the menopause transition.