Dr. Taryl Felhaber (biography and disclosures)
Disclosures: I have in the past given talks for Novo-Nordisk and Merck, but nothing since February 2014. Mitigating Potential Bias: Recommendations are consistent with current practice patterns; Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements.
What I did before
Every woman transitions through menopause, although not all women have bothersome symptoms. Some women’s symptoms may be so disturbing as to lead them to think they are dying, as was the case with a patient in my practice several years ago. Her hot flashes and night sweats (together known as vasomotor symptoms, or VMS), vaginal dryness, mood swings, brain fog, insomnia and joint pains led her to think she must have a terminal illness. Prior to seeking medical advice, she had been too terrified to discuss this with anyone for months.
VMS can be troublesome, occasionally embarrassing, and are often a reason for women to seek the advice of a health practitioner. Menopause induced by surgery, chemotherapy and/or radiation therapy for cancer may be accompanied by severe VMS (1).
As the symptoms of menopause are related to estrogen deficiency, it is no surprise that hormone therapy is the most effective treatment (1). However, women who have had estrogen-sensitive cancers should avoid treatment with hormone therapy. Many women not afflicted with cancer also choose not to use hormone therapy, and look for direction from their Health Care Provider for advice what to do.
Numerous alternatives to hormone therapy have been studied, many in randomized-control trials, over the past decade. The MsFLASH network of collaborating centres, for example, have studied anti-depressants, yoga, mindfulness and other interventions (2, 3, 4, and others). One difficulty cited in determining effectiveness in VMS treatment trials has been the placebo improvement rate between 20 to 60% (5).
What changed my practice
The North American Menopause Society (NAMS) has been working to encourage research and education about menopause since 1988. They publish the journal Menopause and periodically release position papers on topics of concern, including previous statements on hormone treatment in 2012 (6) and treatment of vulvovaginal atrophy in 2013 (7). In late 2015, NAMS published a position paper on recommendations for nonhormonal management of menopause-associated vasomotor symptoms. NAMS evidence-based position was based on review of 340 original research articles and 105 systematic reviews, the majority of which were published between 2005 and 2015. The article reviews the levels of evidence available for use of behavioral, herbal and nonhormonal pharmacologic treatments (5).
The recommended treatments to ease distressing menopausal symptoms include cognitive-behavioral therapy, and to a lesser extent clinical hypnosis, which have been shown to decrease VMS. SSRIs (paroxetine, citalopram, escitalopram), SNRIs (venlafaxine, desvenlafaxine), gabapentinoids (gabapentin and pregabalin) and clonidine have all been shown to have efficacy in reducing VMS.
Therapies that are recommended with caution include weight loss, mindfulness-based stress reduction, the S-equol derivatives of soy isoflavones, and stellate ganglion blockade; further studies are warranted.
Not recommended at present are cooling techniques, avoidance of triggers, exercise, yoga, paced respiration, OTC supplements and herbal products, acupucture, calibration of neural oscillations (I don’t know either) and chiropractic interventions. The reviewers found there were negative, insufficient or inconclusive data on these therapies to permit their recommendation as proven therapies for VMS management.
What I do now
Women often find reassurance in reliable information about menopausal symptoms and available treatments. Many women find it difficult to locate trustworthy advice about menopause on the internet, where savvy marketers using search engine optimization dominate search results. The NAMS website, www.menopause.org has excellent information for patients and their Health Care Providers. NAMS also released an app called MenoPro in 2015 (8), which is designed with both Health Care Provider and patient algorithms for management of menopausal symptoms, with the facility to email the results to the patient and to their EMR.
The information in the 2015 NAMS position statement allows Health Care Providers to recommend evidence-based alternative treatments to hormone therapy with confidence. Despite lack of specific recommendation for the treatment of VMS, the benefits of a healthy diet, with weight loss if necessary, and regular exercise are well known and recommended for everyone.
References
- Davis, S. R., et al. Menopause. Nature Reviews Disease Primers Article number: 15004 (2015) View
- Sternfeld, B., Guthrie K.A. et al. Efficacy of exercise for menopausal symptoms: a randomized controlled trial. Menopause 21 (4):330 (2014). (View with CPSBC or UBC) DOI: 1097/GME.0b013e31829e4089
- Newton, K.M., Reed, S.D. et al. Efficacy of yoga for vasomotor symptoms: a randomized controlled trial. Menopause 21(4): 339 (2014). (View with CPSBC or UBC) DOI: 1097/GME.0b013e31829e4baa
- Cohen, L.S., Joffe, H. et al. Efficacy of omega-3 for vasomotor symptom treatment: a randomized control trial. Menopause 21(4): 347 (2014). (View with CPSBC or UBC) DOI: 10.1097/GME.0b013e31829e40b8
- Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of the North American Menopause Society. Menopause 22(11): 1155-74 (2015). (View with CPSBC or UBC) DOI: 10.1097/GME.0000000000000546
- The 2012 Hormone Therapy Position Statement of the North American Menopause Society. Menopause 19(3): 257-271 (2012). (View with CPSBCor UBC) DOI: 10.1097/gme.0b013e31824b970a
- Management of Symptomatic Vulvovaginal Atrophy: 2013 Position Statement of the North American Menopause Society. Menopause 20 (9): 888-902 (2013). (View with CPSBC or UBC) DOI: 10.1097/gme.0b013e3182a122c2
- Manson, J. E. et al. Algorithm and mobile app for menopausal symptom management and hormonal/ non-hormonal therapy decision making: a clinical decision-support tool from The North American Menopause Society. Menopause 22(3), 247–253 (2015). (View with CPSBC or UBC) DOI: 10.1097/gme.0000000000000373
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I would be interested in results of studies comparing oral or topical progesterone supplementation to placebo for management of VMS.
Good idea to use website. I like the relevant patient case example. Congratulations.
i would be interested in comments on the benefits of vitamin therapy for VMS and mood changes associated with menopause which I have used effectively albeit anecdotally for many years, i enjoyed the article and found it honest, forthright and most helpful
Susanne: The dictum, at least in North America, is that topical progesterone does not provide consistent, predictable and/or adequate levels to protect the endometrium when used together with estrogen. It’s use alone for the management of VMS is not recommended by any of the guideline-producing menopause societies, as far as I am aware. I have asked the library to do a literature search, and will share the results when available.
Barbara: Thank-you.
Judith: A review in the Natural Medicines Comprehensive Database notes studies on several natural products, including black cohosh, St. John’s wort, evening primrose oil, wild yam, chasteberry, dong quai, ginseng, DHEA, among others. The only vitamin specifically noted is Vitamin E, which is listed has having insufficient evidence to recommend use. Given the high placebo response rate of many treatments for menopausal symptoms, if an OTC product is helping someone and being used at a safe dose, I wouldn’t stop it.
Very well said about the treatments of this most confused condition yet a real challenging phase of most women. Thank you for your honest presentation. This will indeed change my concept of treatment.
Given the discontinuation syndrome that many patients experience trying to get OFF SSRIs and SNRIs… and the increased sweating, weight gain & insomnia whilst ON them, I am always amazed that women are willing to try antidepressants for menopausal symptoms, but it does speak to the desperation some experience due to these symptoms. I have found clonidine more helpful in those who feel they truly need meds when other measures have failed. I am a psychiatrist and comfortable prescribing all antidepressants but not necessarily for this indication. I thought your discussion was excellent.
For using SSRI to treat VMS how long patient can be kept on that?