Patient education: Nonhormonal treatments for menopausal symptoms (Beyond the Basics)
- Richard J Santen, MD
Richard J Santen, MD
- Professor of Medicine
- University of Virginia Health Sciences Center
- Charles L Loprinzi, MD
Charles L Loprinzi, MD
- Regis Professor of Breast Cancer Research
- Mayo Clinic College of Medicine
- Section Editors
- Peter J Snyder, MD
Peter J Snyder, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Pituitary Disease; Male Reproductive Endocrinology
- Professor of Medicine
- University of Pennsylvania School of Medicine
- William F Crowley, Jr, MD
William F Crowley, Jr, MD
- Section Editor — Female Reproductive Endocrinology
- Daniel K Podolsky Professor of Medicine
- Harvard Medical School
During a woman's reproductive years, the ovaries produce estrogen and progesterone. Estrogen is important for normal menstrual periods and fertility, and it promotes bone strength. Estrogen and progesterone levels fall at the time of menopause, causing well-known symptoms such as hot flashes.
Postmenopausal hormone therapy is the term used to describe the two hormones (estrogen and progesterone) that are often given to relieve menopausal symptoms. For women whose uterus has been removed, estrogen alone can be given. For others, both estrogen and synthetic or natural progesterone are given. Estrogen is the most effective treatment available to relieve bothersome symptoms of menopause. However, some women cannot take estrogen; for example, women with breast cancer. Other women choose not to take hormone therapy. Fortunately, there are some alternatives to hormone therapy to treat menopausal symptoms. Although they may not be as effective as estrogen, they do provide some relief.
This article discusses alternatives to postmenopausal hormone therapy. A separate article discusses the risks, benefits, and options for hormone therapy. (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)
CONTROLLING HOT FLASHES
Non-estrogen treatments for hot flashes are effective in many women. None work as well as estrogen, but they are better than placebo (sugar pills). Not all women need treatment for hot flashes, since they are mild in some women. Options include:
Paroxetine — Paroxetine (sample brand name: Brisdelle) is the only nonhormonal therapy that is specifically approved for hot flashes (in the United States). This agent has been used for many years for depression but can be taken at a lower dose for hot flashes.
Gabapentin — Gabapentin (sample brand name: Neurontin) is a drug that is primarily used to treat seizures. It also relieves hot flashes in some women, preferably given as a single bedtime dose or during the daytime as well.
Antidepressants — Antidepressant medications are recommended as a first-line treatment for hot flashes in women who cannot take estrogen. Paroxetine is the only drug approved in the United States for hot flashes in this class, but each of these agents has been used for hot flashes.
●Venlafaxine (brand name: Effexor), desvenlafaxine (brand name: Pristiq), citalopram (brand name: Celexa), and escitalopram (brand name: Lexapro) were developed to treat depression, but studies show that they are an effective treatment for hot flashes. Paroxetine (sample brand name: Brisdelle, Paxil) is also effective for hot flashes, but you should not take paroxetine if you have breast cancer and are taking tamoxifen. The concern is that paroxetine can interfere with tamoxifen and make it less effective.
●Fluoxetine (brand name: Prozac) and sertraline (brand name: Zoloft) do not work as well as the other antidepressants listed.
Other antidepressant side effects and interactions are discussed in detail in a separate article. (See "Patient education: Depression treatment options for adults (Beyond the Basics)".)
Progesterone — The injectable progestin birth control hormone medroxyprogesterone acetate (brand name: Depo-Provera) helps to reduce hot flashes but is not commonly used.
Plant-derived estrogens (phytoestrogens) — Plant-derived estrogens have been marketed as a "natural" or "safer" alternative to hormones for women with menopausal symptoms. Phytoestrogens are found in many foods, including soybeans, chickpeas, lentils, flaxseed, lentils, grains, fruits, vegetables, and red clover. Isoflavone supplements, a type of phytoestrogen, can be purchased in health food stores.
However, it is uncertain whether phytoestrogens help to reduce hot flashes or night sweats; most studies have not reported benefit. In addition, some phytoestrogens might act like estrogen in some tissues of the body. Many experts suggest that women who have a history of breast cancer should avoid phytoestrogens.
Herbal treatments — A number of herbal treatments have been promoted as a "natural" remedy for hot flashes. In fact, many postmenopausal women use black cohosh for hot flashes, but clinical trials have shown that it is not more effective than placebo. There have been concerns that black cohosh could stimulate breast tissue like estrogen, increasing the risk of recurrence in women who have had breast cancer. So far, there is no evidence that it is harmful, even in women with breast cancer. Still, some experts suggest that women with breast cancer avoid black cohosh until this has been studied more extensively. Herbal treatments are not recommended for hot flashes or other menopausal symptoms.
Cognitive behavioral and other treatments — Stress management, relaxation, deep breathing, and yoga might be helpful for some women, but study results have been inconsistent. Other approaches such as hypnosis, stellate ganglion blockade (numbing of a nerve in the neck with an injection), and acupuncture reduce hot flashes, but they might work at least in part due to a placebo effect.
TREATING VAGINAL DRYNESS
Low-dose vaginal estrogen is a very effective treatment for postmenopausal women with vaginal dryness or pain with intercourse. This is a treatment that women can continue for many years after menopause because only minimal amounts get into the bloodstream. On this basis, low-dose estrogen is not thought to increase the risk of breast cancer, heart attack, or stroke. This is discussed in more detail in a separate article. (See "Patient education: Vaginal dryness (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION
Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Menopausal hormone therapy (Beyond the Basics)
Patient education: Bone density testing (Beyond the Basics)
Patient education: Osteoporosis prevention and treatment (Beyond the Basics)
Patient education: Calcium and vitamin D for bone health (Beyond the Basics)
Patient education: Vitamin D deficiency (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)
Patient education: Diet and health (Beyond the Basics)
Patient education: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)
Patient education: Depression treatment options for adults (Beyond the Basics)
Patient education: Vaginal dryness (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Overview of androgen deficiency and therapy in women
Clinical manifestations and diagnosis of genitourinary syndrome of menopause (vulvovaginal atrophy)
Estrogen and cognitive function
Menopausal hot flashes
Menopausal hormone therapy and cardiovascular risk
Menopausal hormone therapy and the risk of breast cancer
Postmenopausal hormone therapy in the prevention and treatment of osteoporosis
Menopausal hormone therapy: Benefits and risks
Preparations for menopausal hormone therapy
Treatment of menopausal symptoms with hormone therapy
Treatment of genitourinary syndrome of menopause (vulvovaginal atrophy)
The following organizations also provide reliable health information.
●Hormone Health Network
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.