Experts lay out options for menopause symptoms

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Evidence grows that antidepressants can help, new guidelines say.

24 dec 2013—Women bothered by hot flashes or other effects of menopause have a number of treatment options—hormonal or not, according to updated guidelines from the American College of Obstetricians and Gynecologists.

It's estimated that anywhere from 50 percent to 82 percent of women going through menopause have hot flashes—sudden feelings of extreme heat in the upper body—and night sweats. For many, the symptoms are frequent and severe enough to cause sleep problems and disrupt their daily lives. And the duration of the misery can last from a couple years to more than a decade, says the college, the nation's leading group of ob/gyns.

"Menopausal symptoms are common, and can be very bothersome to women," said Dr. Clarisa Gracia, who helped write the new guidelines. "Women should know that effective treatments are available to address these symptoms."

The guidelines, published in the January issue of Obstetrics & Gynecology, reinforce some longstanding advice: Hormone therapy, with estrogen alone or estrogen plus progestin, is the most effective way to cool hot flashes.

But they also lay out the growing evidence that some antidepressants can help, said Gracia, an associate professor of obstetrics and gynecology at the University of Pennsylvania in Philadelphia.

In studies, low doses of antidepressants such as venlafaxine (Effexor) and fluoxetine (Prozac) have helped relieve hot flashes in some women. And two other drugs—the anti-seizure drug gabapentin and the blood pressure medication clonidine—can be effective, according to the guidelines.

So far, though, only one non-hormonal drug is actually approved by the U.S. Food and Drug Administration for treating hot flashes: a low-dose version of the antidepressant paroxetine (Paxil).

And experts said that while there is evidence some hormone alternatives ease hot flashes, none works as well as estrogen and estrogen-progestin.

"Unfortunately, many providers are afraid to prescribe hormones. And a lot of the time, women are fearful," said Dr. Patricia Sulak, an ob/gyn at Scott & White Hospital in Temple, Texas, who was not involved in writing the new guidelines.

Years ago, doctors routinely prescribed hormone replacement therapy after menopause to lower women's risk of heart disease, among other things. But in 2002, a large U.S. trial called the Women's Health Initiative found that women given estrogen-progestin pills actually had slightly increased risks of blood clots, heart attack and breast cancer.

"Use of hormones plummeted" after that, Sulak noted.

But research since then has suggested that hormone therapy is safer for relatively younger women who start using it soon after menopause, the report notes. Women in that landmark study were in their early 60s, on average—whereas U.S. women typically hit menopause at around age 51.

Experts now say that women should not take hormones to prevent any chronic ills. But when it comes to hot flashes, hormone therapy remains the most effective option.

Another ob/gyn agreed that doctors and women alike are often reluctant to consider hormones. "Since the [Women's Health Initiative], we've been like little fishes swimming upstream," said Dr. Jill Rabin, of Long Island Jewish Medical Center in New Hyde Park, N.Y.

To help minimize any risks, she said, it's important to keep the hormone dose at the lowest level needed to relieve a woman's symptoms.

Sulak agreed. "I'm an estrogen minimalist," she said. "I'm going to start you at a low dose, and that's enough for most women."

Women who should not try hormones, she noted, include those who've ever had breast cancer or a blood clot.

Hot flashes and night sweats are the most common menopause complaint. But vaginal dryness and pain during sex are also issues for many women.

The guidelines say that estrogen applied directly to the vagina—in the form of creams, tablets or rings—is effective. "Very little" of that estrogen gets into the bloodstream, Sulak said, so the risk of side effects is considered small.

And just this year, the FDA approved a new option for treating painful sex in postmenopausal women. It's a pill called ospemifene (Osphena), and it has estrogen-like effects on the lining of the vagina.

As for "natural" remedies, such as soy and black cohosh, studies have failed to prove they're effective for hot flashes and night sweats, the guidelines say.

However, Rabin said that some women who try supplements do feel better—even if it's by a "placebo effect."

There are some "common sense" tactics any woman can use to help ease hot flashes, the guidelines say. Those include dressing in layers, keeping the thermostat lower at home and drinking cool beverages.

But for women who need more than that, Gracia advised talking to your doctor about the benefits and risks of all your options. "Therapy should be individualized, since one therapy may not be optimal for allwomen."

More information: The U.S. National Institute on Aging has more on menopause.