As women’s health care providers, most of us understand the effectiveness of estrogen for symptom alleviation in these women. What becomes perplexing is which route, dose, and duration to prescribe. We have an array of estrogen preparations to choose from, including pills, patches, gels, sprays, as well intranasal and buccal systems (Table).
|TABLE. TREATMENT OPTIONS FOR VASOMOTOR SYMPTOMS RELATED TO MENOPAUSE|
|Treatment||Dosage/Regimen||Evidence of Benefits||FDA Approved|
|Estrogen alone or combined with progestin|
|Conjugated estrogen 0.625 mg/d||Yes||Yes|
|Micronized estradiol-17β 1 mg/d||Yes||Yes|
|Transdermal estradiol-17β 0.0375–0.05 mg/d||Yes||Yes|
|Conjugated estrogen 0.3–0.45 mg/d||Yes||Yes|
|Micronized estradiol-17β 0.5 mg/d||Yes||Yes|
|Transdermal estradiol-17β 0.025 mg/d||Yes||Yes|
|Micronized estradiol-17β 0.25 mg/d||Mixed||No|
|Transdermal estradiol-17β 0.014 mg/d||Mixed||No|
|Estrogen + estrogen agonist/antagonist||Conjugated estrogen 0.45 mg/d and bazedoxifene 20 mg/d||Yes||Yes|
|Progestin||Depot medroxyprogesterone acetate||Yes||No|
|Compounded bioidentical hormones||No||No|
|SSRIs and SSNRIs||No||No|
|Adapted from ACOG practice bulletin no. 141: management of menopausal symptoms. Obstet Gynecol. 2014.1|
There is good evidence that oral and transdermal low-dose estrogen regimens effectively alleviate vasomotor symptoms. However, the extent of symptom improvement with low-dose and ultra–low-dose preparations is not yet well understood, although response to any HRT is variable.1
The major risks of combined HRT are thrombosis and breast cancer. (Note: Endometrial cancer is a risk of unopposed estrogen for women with uteri.) Most trials assessing the safety of HRT have studied equine estrogen and medroxyprogesterone acetate. The findings from the Women’s Health Initiative (WHI), which studied a large cohort of healthy menopausal women aged 50 to 77 years, indicated a slightly increased risk of breast cancer, cardiovascular disease, stroke, and venous thromboembolism (VTE) and a decreased risk of fracture and colon cancer after 5 years of combined HRT.4 Estrogen alone was associated with an increased risk of VTE only. Despite these risk associations, this data should not discourage us from recommending HRT to the appropriate patient, and even ACOG is on board with that thought.
“It is difficult to generalize these findings to younger women who are recently menopausal because the WHI was assessing HT for primary CHD prevention in women, many of whom were past the menopause transition,” responded ACOG to the WHI results.1
Given the variable response to HRT and the associated risks, it is recommended that health care providers individualize care and treat women with the lowest effective dose for the shortest duration that is needed to relieve vasomotor symptoms.1 This makes good clinical sense, and we should encourage our patients to adhere to such a regimen.
Last but not least, we should stress the importance of simple lifestyle modification as adjuncts to symptom control, including the following:
- Regular rigorous exercise.
- Healthy and calorie-appropriate diet.
- Limited alcohol intake.
- Wearing layered breathable clothing.
- Stress reduction techniques, such as deep breathing, personal time, and yoga.
1. ACOG practice bulletin no. 141: management of menopausal symptoms. Obstet Gynecol. 2014;123:202-216.
2. Thurston RC, Joffe H. Vasomotor symptoms and menopause: findings from the Study of Women’s Health Across the Nation. Obstet Gynecol Clin North Am. 2011;38:489-501.
3. MacLennan AH, Broadbent JL, Lester S, Moore V. Oral oestrogen and combined oestrogen/progestogen therapy versus placebo for hot flushes. Cochrane Database System Rev. 2004;4:CD002978. DOI: 10.1002/14651858.CD002978.pub2.
4. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. Writing Group for the Women’s Health Initiative Investigators. JAMA. 2002;288:321-333.