Menopause 2014: An Update from the American College of Physicians Annual Meeting 2014

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June 2, 2014

Although the existence of “Andropause” is very controversial in the medical community, there is no doubt that every woman goes through menopause, whether surgically induced or as a natural consequence of aging.  In the United States, the average age of menopause is 51 years of age.  So to balance out my last article on Andropause, here is the latest update on Menopause.   Dr. Janet Pregler, MD, FACP, Director of the Iris Cantor UCLA Women’s Health Center at the UCLA School of Medicine presented new information at the American College of Physicians Annual Meeting as well as reaffirming previous findings regarding menopause symptoms and treatment. 

1.       What are symptoms of menopause?

Vasomotor symptoms, described as “hot flashes”, where women feel severe heat sensations, flushing, turning red and sweating can occur day and night.  Many patients have night sweats.  African American and Latino patients often have symptoms for longer than other races.  Heavier women and smokers also have increased symptoms.  Smokers tend to enter menopause earlier.

Interestingly, patients without vasomotor symptoms can still suffer from sleep disturbance, depression and memory trouble.  Dr. Pregler reports that “perimenopause is bad for your brain, but it bounces back in postmenopause.”

2.       What are the best ways to treat hot flashes and night sweats?

Estrogen and progesterone, also known as hormone replacement therapy (HRT) remains the most effective treatment for vasomotor symptoms, reducing symptoms by 80-90%.  Overall risks are low for otherwise healthy women at the time of menopause.  Women with a uterus should not take estrogen without progesterone, as estrogen alone can increase the risk of endometrial (the lining of the uterus) cancer.

3.       Should I take estrogen and progesterone to lower my risk of chronic disease like stroke and heart attack?

No, the evidence shows that long term use of hormones for chronic disease prevention is not recommended.  Stroke, breast cancer, coronary artery disease, deep venous thrombosis (blood clots in the veins), dementia (in women over 65), and pancreatitis have been shown to increase in women on long term hormone replacement therapy.  Therefore, the recommendation by the American College of Obstetrics and Gynecologists states, “menopausal hormone therapy should not be used for the primary or secondary prevention of coronary heart disease at the present time”, but that “recent evidence suggests that women in early menopause who are in good cardiovascular health are at low risk of adverse cardiac outcomes and should be considered candidates (for hormone therapy) for relief of menopausal symptoms. 

In other words, hormone replacement therapy should be used for relief of hot flashes and vasomotor symptoms but should not be used to prevent chronic diseases.

4.       What are the benefits and risks of HRT?

Being the best at lowering vasomotor symptoms, hormone replacement therapy also decreases vaginal atrophy and helps with prevention of urinary tract infections and treatment of vaginal dryness.  Risks of hormone therapy include breast tenderness, menstrual bleeding, kidney stones and gallstones.  Long term risks include increased risk of blood clots, stroke, coronary artery disease, and pancreatitis, as stated in the previous question.

5.       What are options for hormone replacement therapy?  What about over the counter treatments?

Several alternative treatments are advertised as relieving hot flashes and night sweats.  When studied in placebo controlled, double blinded trials, they turn out to be no better than placebo.  Specifically studies on Black Cohosh, multibotannicals, and soy showed no difference compared with placebo.  There are several prescription medications that are used “off label” for treatment of hot flashes.  Paxil (generic name is Paroxetine) does have the indication from the FDA for use in vasomotor symptoms.  Other medications that decrease symptoms are Venlafaxine (Effexor), Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro), Gabapentin (Neurontin), Pregabalin (Lyrica), and Clonidine.  Regarding sleep disturbance, many women use sleeping medicines during perimenopause such as Zolpidem (Ambien).  Seventy percent of women in one trial on Zolpidem reported better sleep compared to forty percent of women on placebo.

In summary, there are many options to discuss with your personal physician when facing symptoms of menopause.  Hormone replacement therapy remains the best treatment for hot flashes and vasomotor symptoms.  Be reassured that many of these symptoms will eventually disappear and even sleep disturbance and memory issues will improve.  Excelletn related articles on this website have been posted in the last year:

1)  Dr. Thu Tran’s article on Hot Flashes and Some Remedies:

2)  Dr. Geetha Pinto’s article on Hormone Replacement and Heart Disease: