Medications

Estrogen therapy

Estrogen is a well-established prescription therapy for hot flashes. Estrogen also helps build bone mass, reduces the risk of fractures, and improves cholesterol levels. Estrogen can also be helpful in preventing urinary symptoms and in treating uncomfortable vaginal symptoms. Hormone therapy (HT) also referred to as hormone replacement therapy (HRT), consists of estrogens or a combination of estrogens and progesterone (progestin).

Long-term studies of women receiving combined HT with estrogen and progesterone showed an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. Studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer. Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus).

More recently, studies have suggested that the cardiovascular risks associated with hormone therapy may be more relevant for older postmenopausal women rather than those in the perimenopause or early postmenopausal period. The decision regarding hormone therapy, therefore, should be individualized by each woman and her healthcare professional based on her medical history, the severity of the symptoms, and the potential risks and benefits of hormone administration.

Estrogen is available in a variety of forms, including vaginal suppositories and creams (which are mainly useful for vaginal symptoms), skin patches (Vivelle, Climara, Estraderm, Esclim, Alora), and oral tablets.

Women should undergo a breast exam and mammogram prior to starting estrogen. Once on estrogen, women must be monitored regularly with breast exams and mammograms.

Women who already have heart disease should not use estrogen.

Estrogen therapy does not prevent pregnancy.

Women who take estrogen also tend to have a higher risk of developing:

• Gallstones
  
  
• Increased triglyceride levels
  
  
• Blood clots
  
  
• Vaginal dryness and pain with intercourse

Bioidentical hormone therapy

There has been increasing interest in recent years in the use of so-called "bioidentical" hormone therapy for perimenpausal women. Bioidentical hormone preparations are medications that contain hormones that have the same chemical formula as those made naturally in the body. The hormones are created in a laboratory by altering compounds derived from naturally-occurring plant products. Some bioidentical hormone preparations are made at special pharmacies called compounding pharmacies, which make the preparations on a case-by-case basis for each patient. These individual preparations are not regulated by the FDA, because compounded products are not standardized.

Advocates of bioidentical hormone therapy argue that the products, applied as creams or gels, are absorbed into the body in their active form without the need for "first pass" metabolism in the liver and that their use may avoid potentially dangerous side effects of synthetic hormones used in conventional hormone therapy. However, studies to establish the long-term safety and effectiveness of these products have not been carried out.

Medications other than estrogen

The class of drugs known as selective serotonin reuptake inhibitors (SSRIs), typically used in the treatment of depression and anxiety, has been shown to be effective in reducing menopausal hot flashes. The SSRI that has been tested most extensively is venlafaxine (Effexor), although other SSRI drugs may be effective as well.

Clonidine (Catapres) is a drug that decreases blood pressure. Clonidine can effectively relieve hot flashes in some women. Side effects include dry mouth, constipation, drowsiness, and difficulty sleeping.

Gabapentin (Neurontin), a drug primarily used for the treatment of seizures, has also been used successfully to treat hot flashes.

Progestin drugs have also been successfully used to treat hot flashes. Megestrol acetate (Megace) is sometimes prescribed over the short-term to help relieve hot flashes. Serious effects can occur if the medication is abruptly discontinued, and megestrol is not usually recommended as a first-line drug to treat hot flashes. An unpleasant side effect of Megestrol is that it may lead to weight gain. Another form of progesterone, medroxyprogesterone acetate (Depo-Provera) administered by injection, can also sometimes be useful in treating hot flashes, but may also lead to weight gain as well as bone loss.

Bone loss

Several medications may be used for preventing and treating osteoporosis.

• The bisphosphonates, which include alendronate (Fosamax) and risedronate (Actonel), have been shown in clinical trials to reduce bone loss in postmenopausal women and to reduce fracture risk in women who have osteoporosis.
  
  
• Raloxifene (Evista), a selective estrogen receptor modulator (SERM), is another therapy for osteoporosis. It reduces bone loss and appears to reduce the risk of back fractures in women with osteoporosis.
  
  
• Calcitonin (Miacalcin or Calcimar) is a nasal spray that has been found to reduce the risk of back fractures in women who have osteoporosis.
  
  
• A prevention drug that may also be effective is PTH (parathyroid hormone), but this is not a usual first-line treatment.

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