Managing Menopause- Komen Perspectives

Menopause begins most often in the late forties or early fifties. Medically, a woman is considered in menopause 12 months after her menstrual periods have stopped. However, hot flashes and other symptoms may occur a few years before menopause begins and may continue for five or more years.¹ The severity and duration of symptoms vary from woman to woman. 

The most common menopausal symptoms are hot flashes (including night sweats) and vaginal dryness. If you are having menopausal symptoms, talk to your health care provider about what you can do to try and get relief. To help with that discussion, we offer a summary of the safest, most effective ways to relieve menopausal symptoms for women with and without a history of breast cancer. 

Postmenopausal hormone use for women without a history of breast cancer

Many women use postmenopausal hormones (also known as menopausal hormone therapy or hormone replacement therapy) to relieve hot flashes and other menopausal symptoms. These therapies are approved for the short-term relief of menopausal symptoms, but there are possible health risks with longer term use (see below). The U.S. Food and Drug Administration (FDA) recommends women use only the lowest dose that eases symptoms for the shortest time needed.²   

There are two main types of postmenopausal hormone therapy:  

• Estrogen plus progestin is used by women who have a uterus. 
• Estrogen alone is used by women who no longer have a uterus (who have had a hysterectomy). It is not safe for women with a uterus to take estrogen alone. Progestin is needed to prevent uterine cancer. 

Estrogen plus progestin

Postmenopausal hormone therapy with estrogen plus progestin increases the risk of getting breast cancer.^3-8 In randomized controlled trials, women who took estrogen plus progestin therapy had an increased risk of: ^3-16

• Breast cancer within the first five years of use  
• Having an abnormal mammogram within the first five years of use  
• Ovarian cancer after five years of use 
• Heart disease after five years of use 
• Stroke after five years of use 
• Blood clots (in the legs or lungs) after five years of use  

When women stop taking estrogen plus progestin therapy, their risk of breast cancer starts to decline and over time returns to that of a woman who has never used hormones.^4,6-7,9   

Estrogen alone

At this time, it is unclear how postmenopausal hormone therapy with estrogen alone affects breast cancer risk. The Women’s Health Initiative randomized controlled trial found a decreased risk of breast cancer with estrogen alone compared to placebo after an average of six years of use.¹⁷ However, other studies showed an increased risk, but mainly after longer-term use (10 to 20 or more years).^{4-5,7-8,18-19} Estrogen alone therapy also may increase the risk of stroke, dementia, ovarian cancer and uterine cancer.^4,15-16 Researchers continue to follow the women in studies of estrogen alone therapy to understand better how it might affect breast cancer and other health risks.

Bio-identical hormones

The term “bio-identical hormones” is used to describe drugs that are similar to hormones found in the body or drugs that are custom compounded (when a pharmacist makes a mixture of hormones according to a physician’s instructions on a prescription).^20-21 Bio-identical hormones have not been shown to be safer or more effective at treating menopausal symptoms than FDA-approved postmenopausal hormone therapies. And, because they have not been well-studied, they may have more health risks.^20-21 Learn more about bio-identical hormone therapies on the FDA website.   

Postmenopausal hormone use for women with a history of breast cancer

Some breast cancer survivors go through early menopause due to chemotherapy. Hot flashes and other symptoms may be worse for these women than for women who go through menopause at later ages.²² Survivors may also have hot flashes as a side effect of hormone therapy for breast cancer treatment.   

Although postmenopausal hormone use may relieve these symptoms, there is concern it might increase the risk of breast cancer recurrence in survivors. Some studies have found no link between the two.^23-25 However, two randomized controlled trials found survivors taking postmenopausal hormones had more breast cancer recurrences than survivors not taking postmenopausal hormones.^26-27 Currently, the best choice for most breast cancer survivors is to avoid the use of postmenopausal hormones. Some alternatives to hormones for treating the most common menopausal symptoms are described below. 

Hot flashes

Many alternatives to postmenopausal hormones have been studies for the relief of hot flashes.  Some of these are discussed below. Talk to your health care provider about potential risks and benefits before using any of these therapies.  

Find a summary table of the risk and benefits of non-hormonal therapies used to treat hot flashes and other menopausal symptoms. 

SSRI and non-SSRI antidepressants 

Among the most promising medications for the relief of hot flashes is a group of antidepressants called selective serotonin reuptake inhibitors (SSRIs). SSRIs include citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft). These drugs, and the non-SSRI antidepressant venlafaxine (Effexor), have been shown to decrease the frequency and strength of hot flashes by 50 to 60 percent, with few side effects.^28-34 (Breast cancer survivors taking tamoxifen should talk to their health care provider about a possible interference between SSRIs and tamoxifen.^35-36)  

Other drugs

Gabapentin (Neurontin) is a drug used to treat seizures and pain. Some studies have shown gabapentin reduced hot flashes better than a placebo.^37-41

Megestrol acetate is a drug used at high doses to treat metastatic breast cancer. In low doses, studies have shown it reduced hot flashes in breast cancer survivors.^42-43  

The safety of these drugs for the treatment of hot flashes is still under study. 

Plant-based remedies and vitamin E

Phytoestrogens are chemicals contained in certain plants (such as soy and red clover) that can mimic estrogen in the body. For this reason, phytoestrogens (in foods and in supplement form) have been studied as a way to treat menopausal symptoms. Findings to date are mixed. Most randomized controlled trials have found no benefit for menopausal symptoms from phytoestrogens.^44-48 However, a few studies have shown soy can reduce hot flashes.^48-49 The North American Menopause Society recommends soy (in foods or supplement form) as a reasonable treatment for hot flashes to discuss with your health care provider. If symptoms do not improve after 12 weeks, other options should be considered.⁵⁰

There is little evidence that black cohosh, evening primrose or vitamin E can reduce hot flashes in women with or without a history of breast cancer.^39,51-54  

Acupuncture

A few, small randomized controlled trials have shown acupuncture reduced hot flashes compared to a sham acupuncture treatment, but other studies have found no difference between the two.^55-56

Lifestyle tips for managing hot flashes

Although studies are limited at this time, the following tips may help relieve hot flashes.¹  

• Quitting smoking (if you smoke) 
• Reducing alcohol use (if you drink) 
• Dressing in layers 
• Keeping an ice pack under your bed pillow 
• Avoiding caffeine and hot drinks 
• Avoiding hot or spicy foods 
• Keeping your home or bedroom cool 

Vaginal symptoms

Another common symptom of menopause is vaginal dryness, which can cause pain during intercourse, vaginal soreness and itching. Some methods for relieving vaginal symptoms contain hormones and some do not. Talk to your health care provider about which option is best for you. 

Hormonal options for vaginal symptoms include an estrogen-containing soft ring (put into the vagina like a diaphragm) and vaginal estrogen suppositories. Both slightly increase the level of estrogen in the blood, but for only a short time and most breast oncologists believe they are safe for breast cancer survivors. These products require a prescription. 

A non-hormonal option for the relief of vaginal dryness is an estrogen-free vaginal moisturizer (such as Replens). These products are different from vaginal lubricants (such as K-Y Jelly and Astroglide ) which only make surfaces slippery, rather than moisturizing. For the best effect, moisturizers need to be used regularly, rather than just around the time of intercourse. They are available over the counter (without a prescription).

Find a summary table of the risk and benefits of non-hormonal therapies used to treat vaginal dryness and other menopausal symptoms. 

Summary

Many women seek relief for menopausal symptoms. Although postmenopausal hormone therapies have health risks, short-term use can offer relief for some women without a history of breast cancer safely. For breast cancer survivors or women who want to avoid postmenopausal hormones, certain antidepressants have been shown to relieve hot flashes. And, for women who want to avoid drug therapies, many lifestyle behaviors may help ease hot flashes and vaginal moisturizers can offer relief for vaginal dryness. According to Dr. Wendy Chen, Assistant Professor of Medicine at Harvard Medical School and a medical oncologist at the Dana-Farber Cancer Institute, “although the medical definition of menopause may be the same for all women, the symptoms and side effects for any one woman can be very different. So any treatment that is needed for symptoms of menopause has to be personalized to each woman.” Your health care provider can help you explore your options and find safe and effective ways to ease your symptoms. 

References

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