Menopausal Symptoms
Menopause occurs in the United States at the average age of 51. The classic definition is the absence of menstruation for 1 year in a patient with a uterus. In patients who have had a hysterectomy, then the diagnosis can be made by history of related symptoms or with blood estrogen along with a hormone called FSH measurements.
The 2 most common symptoms are hot flashes and dryness of the vagina. Dryness of the vagina leading to complaints of discharge or pain with intercourse is called atrophic vaginitis. Hot flashes occur in 75 to 80 percent of all women. Hot flashed can start 10 years before the last menstrual cycle and usually self-resolve after 10 years. However, some women can experience them for much longer. Atrophic vaginitis occurs in 40 to 60 percent of women, with 15 percent starting long before the final menstrual cycle. While these conditions are not in general medically harmful, they can severely impact a patient’s quality of life. Fortunately, there are a multitude of treatments including both hormonal and nonhormonal.
Hormonal treatments typically involve estrogen either taken by patch, pill or as a vaginal insertion. If a person has a uterus, not had a hysterectomy, then they need a progesterone or bazedoxifine as well to prevent abnormal bleeding. Other than improving symptoms, estrogen is associated with decreased risk of colon cancer and fractures related to osteoporosis. Estrogen alone is not associated with an increase in breast cancer. Estrogen is associated with a small increase in risk for cardiovascular events (heart attack, stroke), DVT or PE (blood clot in lung or leg). It is an acceptable risk in health patients who have an absolute risk of cardiovascular even of <5% in the next 10 years.
Patients are often concerned about breast cancer risk. Estrogen by itself has not been shown to be associated with increased risk of breast cancer. However, there is increased risk in patients who take estrogen with progesterone. The relative risk is estimated to be 1.023 per year of use to a maximum of 1.35 after 5 years of use. What does this mean?
The average 5-year risk breast cancer risk of a healthy 51-year old is 1.3 percent. If this person takes estrogen and progesterone then the risk is 1.3% x 1.023 or 1.329 percent. Which is still very low. The endocrine society recommends that women with an absolute risk or 1.67 percent can take hormone replacement safely. Caution should be used if the risk is 1.67 to 5 percent.
Vaginally placed estrogens have very low systemic absorption and therefore they are relatively low risk medications.
Examples of medications that treat Hot Flashes
· Hormonal Treatment
o Estrogen only
o Estrogen plus medroxyprogesterone
o Estrogen plus drospiranone
o Estrogen plus dydogesteroen
o Estrogen plus cyproterone acetate
o Estrogen plus bazedoxifine
· Nonhormonal treatment
o Fezolinetant*
o Antidepressant SSRI (Paroxetine*)
o Antidepressant SNRI (Venlafaxine)
o Gabapentin
o Pregabalin
o Oxybutynin
o Clonidine
*FDA approved medication
Examples of medications that treat vaginal symptoms
· Estrogen Treatment
o Estrogen either by pill or vaignal suppository*
· Estrogen agonist/antoagonist Treatment
o Ospemifene*
o Raloxifene and Tamoxifen
· Non-estrogen Hormonal Treatment
o Testosterone
o Vaginal DHEA*
o Tibolone*
· Nonhormonal Treatment
o Lubricants
o CO2 laser
*FDA approved medication
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