Several hormone replacement options are available to relieve hot flushes and vaginal dryness and to prevent osteoporosis, all commonly associated with menopause. Each woman should discuss the various options with her health care provider to determine which therapy is best for her. Pros and cons are associated with each regimen and the choice for a particular woman is determined by her symptoms and medical history.
Estrogen/Progestogen
One of the most effective and commonly used regimens consists of estrogen with or without progestogen. Women who have not had a hysterectomy should take both an estrogen and a progestogen; women without a uterus should receive only the estrogen. When these hormones are given by mouth or by a patch worn on the skin, they affect the whole body and relieve hot flushes, vaginal dryness, and prevent osteoporosis. As shown in the Women's Health Initiative (WHI) trial, published in the Journal of the American Medical Association in 2002, prolonged use and higher doses are associated with an increased risk of coronary heart disease, stroke, blood clots and breast cancer. These risks are minimal if used in the lowest effective dose for the shortest possible duration, usually 2 to 3 years following menopause. The WHI trial found a lower rate of colorectal cancer among hormone users. Different dosing schedules are available, with some causing less uterine bleeding than others.
Vaginal Estrogen Plus Bisphosphonate
If hot flushes are not a problem or if oral or patch hormonal therapy is inappropriate, estrogen given intravaginally can be used to treat vaginal dryness. Estrogen given this way does not prevent bone breakdown, so a bisphosphonate is also commonly used to prevent osteoporosis. Bisphosphonate drugs include alendronate (Fosamax®), ibandronate (Boniva®), risedronate (Actonel®), and zoledronic acid (Reclast®). Adequate amounts of calcium and vitamin D should also be taken to prevent osteoporosis.
Raloxifene
Raloxifene (Evista®) is a non-hormonal drug that mimics the effects of estrogen. It is used for preventing osteoporosis. It does not help hot flushes and may even make them worse. Still, it is safer than estrogen/progestogen for women who are at a high risk for breast cancer, providing some protection against the disease. Blood clots may develop with raloxifene use.
Other Medications
Women experiencing hot flushes who cannot take estrogen/progestogen because of concerns about cardiovascular disease or breast cancer may benefit from a non-hormonal drug such as venlafaxine (Effexor®), paroxetine (Paxil®), fluoxetine (Prozac®), clonidine (Catapres®), or gabapentin (Neurontin®). These drugs are primarily used for other indications and are generally less effective in relieving hot flushes than estrogen/progestogen. They do not prevent osteoporosis, however, so another medication should also be taken for this purpose.
References
- "Pharmacotherapy: A Pathophysiologic Approach"; DiPiro JT, Talbert RL, Yee, GC, et al, editors, 2005. Chapter 80 "Hormone Therapy in Women", Kalantaridou SN, Davis, SR, Calis KA.
- Women's Health Initiative: Risks and Benefits of Estrogen
- "AHFS Drug Information"; McEvoy GK, editor; 2009.
