This lecture was given at Sibley Memorial Hospital in February by Dr. Shawn Davis-Wilensky and Dr. Shannon Green.
Some women go through menopause with severe symptoms and are advised not to use hormonal therapy. Women who have had breast cancer or deep vein thrombosis are at increased risk if they use hormones. So, how do you treat menopausal symptoms if you cannot use hormones?
The North American Menopause Society has collected data on which treatments work and which do not. Most women, 50-80%, try some type of non-hormonal treatment for menopausal symptoms. Most women are not fully informed about the benefits and risk of herbal therapies. Because of these uncertainties, many women use the wrong supplements or inadequate dosing, and suffer from bothersome symptoms when they could be using more successful treatments. Many supplements have risks which are not well known.
What does work?
Two mind-body therapies have proved to be successful in clinical studies. Cognitive behavioral therapy has good evidence of efficacy by reducing the discomfort of symptoms, while not really decreasing the frequency of symptoms. Hypnosis, using the Elkins protocol, has also proved effective. This protocol involves in-person hypnosis and at-home self-hypnosis. In women with more than 50 episodes of vasomotor symptoms per week, the frequency and severity of symptoms were reduced. When breast cancer survivors were treated, there was a significant decrease in symptoms, as well as in improvement in sleep and mood.
Medications that improve menopausal symptoms include antidepressants and gabapentin.
The FDA has approved low-dose paroxetine for the treatment of vasomotor symptoms. Other SSRI’s and SNRI’s have been proven to be effective in case controlled studies. The drugs that have been shown to significantly decrease menopausal symptoms are paroxetine, escitalopram, citalopram, venlaflaxine, and desvenlaflaxine. Your physician can best determine which of these drugs would be best for you while taking into account past history and use of medication, and other medical problems and prescription therapies . If a mood disorder is a significant menopausal symptom, these drugs can be very helpful. These medications are often started at lower doses and titrated up the the most effective dose. The benefits and side effects should be monitored every 6-12 months. It is important when trying to go off of these medications, the dose is tapered over two weeks to minimize side effects.
Gabapentin, which is a drug used for seizures and pain, is also effective. When given before bed, it can be very helpful for patients who suffer from insomnia and night sweats.
Other therapies that show some evidence of benefit include weight loss, mindfulness based stress reduction, the s-equol derivative of soy, and stellate ganglion block (although I have yet to find a practitioner who performs this).
What doesn’t work?
The therapies that have proven to provide not benefit through studies that look at their effectiveness include vitamins, over-the-counter supplements, herbal remedies, chiropractic therapy, and relaxation techniques. For many years, black cohash has been recommended for hot flashes with some anecdotal evidence of success. Although it could be a placebo effect, studies have not shown it to be effective.
Cooling techniques and avoiding triggers are often recommended and may provide some symptomatic relief, but do not actually decrease the frequency and severity of symptoms.
Although providing other health benefits, yoga, exercise and acupuncture have not been found to be effective strategies for the treatment of symptoms.
The bottom line is that there are useful strategies for the prevention of menopausal symptoms in women who cannot or choose not to take hormones, You do not need to suffer, so ask for help and your physician can determine which treatment might be most successful for you.
Marilyn C. Jerome, MD
Foxhall OB-Gyn Associates
North American Menopause Society: Key Points from the 2015 Position Statement of the North American Menopause Society
The November, 2017, issue of the American Journal of Obstetrics and Gynecology
discussed the benefits of removing fallopian tubes at the time of vaginal hysterectomy. Removal of the tubes at the time of abdominal or laparoscopic hysterectomy done for benign disease is becoming more routine. It was thought that removing the tubes during a vaginal hysterectomy would lead to more complications and blood loss, but the study recently published demonstrated that the risks were quite low when compared to the decrease in ovarian cancer and deaths. The authors recommended that prophylactic removal of the fallopian tubes be considered when a vaginal hysterectomy is done. This can be accomplished in about 80% of patients, while in 20% it may not be possible to remove both tubes. Why take out the tubes when not planning to remove the ovaries?
As more prophylactic salpingo-oophorectomies (removal of the tubes and ovaries for prevention) have been performed, largely due to increased testing for the BRCA gene, pathologists have noted that women at high risk for ovarian cancer have been found to have more serous intraepithelial cancers in the fallopian tubes. These are felt to be the precursor lesions for high grade ovarian and peritoneal cancers. The removal of the fallopian tubes can lower the risk of a subsequent diagnosis of ovarian cancer. In women with the BRCA gene, it is recommended that the ovaries be removed after childbearing. Removing ovaries in a premenopausal women can have serious health consequences including menopausal symptoms, vaginal dryness and painful intercourse, and an increased risk of heart disease and osteoporosis. Removal of the fallopian tubes, with subsequent removal of the ovaries after menopause, is a strategy that may reduce ovarian cancer risk, but optimize the benefits of estrogen for women in their 40's who are at risk for ovarian cancer. Although more studies are in progress, the current data points to a favorable risk/benefit ratio in favor of removing fallopian tubes during hysterectomy for benign disease.
Marilyn Jerome, MD
Foxhall Ob-Gyn Associates
American Journal of Obstetrics and Gynecology, November 2017
Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis. Cadish, et al.
Feasibility of prophylactic salpingectomy during vaginal hysterectomy. Antosh, et al.
Prophylactic bilateral salpingectomy at vaginal hysterectomy: time for a "policy"?,
Rosanne Kho, MD