Is It Hot in Here? Menopause Symptom Management

Abstract

•Review of most common complaints of perimenopause.•Discussion of complementary therapies used to treat perimenopausal issues.•Discussion of recent research regarding hormonal treatment of perimenopausal complaints. Perimenopause marks the transition from reproductive to nonreproductive life. The top complaints women seek assistance in coping with during this time of life include painful intercourse, vaginal dryness, night sweats, sleep disturbances, and flushing (vasomotor symptoms, or VMS). Despite the range of symptoms, women are most often interested in what will “fix” the problem. At this point in their lives, they are often experiencing their career peak, and in “sandwich time”—caring for parents and children. Sleep disturbances, hot flashes, and sexual difficulties are simply not on the schedule! So how can we assist them? Regular physical activity has many health benefits, but evidence supporting the popularly held belief that exercise is helpful for alleviating VMS remains controversial.1Sternfeld B. Dugan S. Physical activity and health during the menopausal transition.Obstet Gynecol Clin N Am. 2011; 38: 537-566Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar This contradictory evidence, coupled with the many benefits and minimal risks of exercise, suggests there is a need for carefully designed, randomized, controlled trials to test its efficacy in treating VMS. Yes, is is important to exercise, but maybe not for addressing all perimenopausal symptoms. Sleep disturbances can be an especially troublesome issue. In addition to the hormone changes underlying perimenopause, many factors, both directly related (VMS) and unrelated to the transition (age-related sleep changes, sleep apnea, mood disturbance, relationship and co-sleeping habits), contribute to sleep disturbances. Data from the Study of Women Across the Nation show that the menopausal transition is related to self-reported difficulty sleeping, independent of age. As another source of sleeping difficulty in perimenopausal women, the Study of Women Across the Nation and other studies have shown that vasomotor symptoms are strongly associated with poor sleep quality. However, subgroup analyses restricted to women without vasomotor symptoms also showed an association between perimenopause and poor sleep quality. Sleep quality is not entirely explained by vasomotor symptoms.2Woods N.F. Mitchell E.S. Sleep symptoms during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women’s Health Study.Sleep. 2010; 33: 539-549PubMed Google Scholar Other issues may come into play, so a perimenopausal origin cannot always be assumed. Patients are often interested in “natural treatments” instead of “medicines” for their perimenopausal problems. The herb, black cohosh, has been used to treat menopausal symptoms, such as hot flashes, night sweats, and sleep issues.3Newton K.M. Reed S.D. LaCroix A.Z. Grothaus L.C. Ehrlich K. Guiltinan J. Treatment of vasomotor symptoms of menopause with black cohosh, multibotanicals, soy, hormone therapy, or placebo: a randomized trial.Ann Intern Med. 2006; 145: 869-879Crossref PubMed Scopus (258) Google Scholar Some studies have shown positive results, yet lack rigor and placebo controls. To provide more definitive evidence on the effects of black cohosh on menopausal symptoms, The National Center for Complementary and Alternative Medicine funded a 12-month, randomized, placebo-controlled study to determine whether treatment with this herb is effective in reducing the frequency and intensity of menopausal hot flashes. The study also addressed whether black cohosh reduces the frequency of other menopausal symptoms and improves quality of life, and examined its possible mechanism of action. When black cohosh is used at regular doses, its only known side effect is occasional stomach discomfort. A September 2013 e-newsletter/clinical digest from the National Center for Complementary and Alternative Medicine was dedicated to menopausal symptoms and complementary health practices, and includes a wealth of resources such as clinical guidelines, research, and patient information (http://nccam.nih.gov/health/providers/digest/menopause). Sexual health is critical in relationships. Lower levels of estrogen can cause a drop in blood supply to the vagina, which affects vaginal lubrication, causing the vagina to be too dry for comfortable sexual activity. Vaginal dryness can be treated with water-soluble lubricants, vaginal moisturizers (eg, Replens [Lil' Drugstore Products, Inc., Cedar Rapids, IA], Luvena [Laclede, Inc., Rancho Domiguiez, CA]), or local application of estrogen therapy. VMS have been treated effectively using medications other than hormones. Antidepressant medications, such as venlafaxine (Effexor) and paroxetine (Paxil), can relieve the symptoms of hot flashes in 60% of women. Gabapentin (Neurontin) is moderately effective in treating hot flashes. As its main side effect is drowsiness, taking it at bedtime may also improve sleep while decreasing hot flashes. Clonidine has also been found to relieve hot flashes in some women and is especially useful if the woman also has concomitant hypertension.4Unland E. Falconieri L. Treatment options for vasomotor symptoms in menopause: focus on desvenlafaxine.Int J Womens Health. 2012; 4: 305-319Crossref PubMed Google Scholar The North American Menopause Society revised its 2005 statement based on the latest research (2012) regarding the use of both estrogen therapy (ET) and estrogen and progestin therapy in treating menopausal symptoms. The statement reaffirms that hormone therapy is the most effective treatment for vasomotor symptoms and other symptoms of menopause. However, now with a decade of research findings since the publication of the first results from the Women's Health Initiative, it has become clear that there are important distinctions between estrogen plus progestin and estrogen alone in terms of benefits and risks. In addition, the benefit/risk profile of hormone therapy can vary based on the woman's age, time since menopause, and her personal risk-factor profile. Previous guidelines recommended avoiding treatment with hormones for more than 5 years, stating that estrogen plus progestin is linked to an increased risk for breast cancer after 3 to 5 years. Current guidelines suggest that there may be more flexibility in terms of duration of treatment for women taking estrogen alone. For ET, no sign of increased risk of breast cancer was seen during an average of 7 years of treatment. This allows more choice in how long to use ET. It has been suggested that treatment with hormone therapy should be individualized. There is no “one-size-fits-all” approach to hormone therapy decision-making, and it will depend greatly on each woman's preferences, impairment of quality of life, severity of symptoms, and personal risk-factor profile (http://www.menopause.org/publications/other-resources/nams-and-uspstf-statements-consistent).“These are not hot flashes—they are power surges!” Section Editor Laurel Halloran, PhD, APRN, is coordinator of the master’s program in nursing at Western Connecticut State University and a family nurse practitioner. She can be reached at .