New Guidelines for the Treatment of Menopause Symptoms

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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Is there anything new for menopause?

Well, yes there is. 2014 brought some new guidelines by the American College of Obstetricians and Gynecologists for the treatment of symptoms of menopause: hot flashes and vaginal dryness/atrophy.

No new risks or dangers.

The good news is the guidelines didn’t raise any risks or dangers that we didn’t already know, for the medications or treatments we have been using. That’s good.

More of the same?

While the hormone therapy recommendations are similar to prior recommendations, there is more evidence to support non-hormonal alternatives. These are the antidepressants that are used for insomnia and hot flashes such as selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors—examples being Lexapro (escitalopram), Effexor (venlafaxine), Cymbalta, etc. What is interesting is that only the 7.5mg per day dose of SSRI paroxetine is actually FDA approved for menopause symptoms, but many SSRIs are used. Paroxetine is available as Brisdelle (7.5 mg) and Paxil (10 mg, 20 mg, 30 mg, and 40 mg).

What’s new?

There are some really cool new medications coming your way for menopause. Duavee is the first. Newer meds like Duavee combine selective estrogen modulators (SERMS) and estrogen in one pill. What this accomplishes is using estrogen for the “good” things (bones, the vagina, reducing hot flashes) and blocking it’s effects for the “bad” things like breast cancer. This is major for sufferers of hot flashes, as 87% suffer daily if they do have them and they last on average 4 to 10 years. Another new medication for vaginal dryness and pain during intercourse is Osphena (ospemifene), which is a tablet you take daily.

What are the risks of standard hormone replacement therapy (HRT)?

Remember that standard estrogen/progesterone hormone replacement therapy (Prempro, Activella, Climara Pro patch, etc) carries a higher risk of clotting in the leg (venous thromboembolism) and breast cancer. Because the risks outweigh the benefits it is not recommended that everyone take HRT, only those with refractory hot flashes, among other things. Separate this in your mind from the newer meds like Duavee which don’t cause the same risks. If you do take HRT, the patches are safer than pills.

What not to do:

These guidelines also point out what to avoid: progestin alone increases breast cancer risk, and testosterone poses no benefit (minor improved sexual satisfaction at high doses), but comes with multiple risks. Too little evidence supports the benefit of compounded bioidentical hormones, phytoestrogens, herbal remedies, or exercise. Clonidine and gabapentin have shown some efficacy but are not FDA-approved for treating menopausal symptoms.

Dr O.

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