Hormone Therapy Still Gold Standard for Hot Flushes

Vasomotor flushes, better known as hot flushes, can be the bane of a woman’s existence during menopause, but treating these symptoms should not put her at risk for other health problems. Despite the Women’s Health Initiative (WHI) findings regarding hormone therapy (HT), it is still the “gold standard” for the treatment of hot flushes, said Isaac Schiff, MD, Chief, Vincent Obstetrics and Gynecology Service, Massachusetts General Hospital, and Joe Vincent Meigs Professor of Gynecology, Harvard Medical School, Boston, MA.

“Hormone therapy remains an appropriate treatment option for women with moderate-to-severe vasomotor symptoms,” Dr Schiff said at the ACOG meeting.

Acknowledging the concern surrounding HT in the wake of the WHI as well as the complexity of HT treatment decisions, he discussed options for practitioners, including modes of administration for, and alternatives to, HT.

“There is no right answer—it has to be individualized,” he said.

According to Dr Schiff, the prevalence of hot flushes tends to occur between 1 and 2 years of menopause but can continue up to 10 years after onset. Despite past belief that only thin women experienced hot flushes, the Study of Women’s Health Across the Nation (SWAN) showed that hot flushes actually increase with higher body mass index, he said.

Although SWAN showed that hot flushes are associated with increased aortic calcification, other studies have shown differing results. “All across the board, women who had vasomotor symptoms tended to have lower bone density,” Dr Schiff said.

According to Dr Schiff, menopausal women are the best candidates for HT, and health practitioners should use the lowest possible dose for the shortest duration. High doses of estrogen can cause breakthrough bleeding, he said, and when using estrogen in combination, the dose should be lowered. Patients should be evaluated annually during treatment with HT to weigh the risks and benefits.

In discussing delivery modes for HT, Dr Schiff said a low-dose transdermal patch can be an attractive option, because it reduces hot flushes while helping to increase bone mineral density. “It appears that the transdermal patch will result in fewer cases of phlebitis,” he said, because it bypasses the liver. In addition, oral HT confers a higher risk of venous thromboembolism compared with the patch.

Other good options for low-dose HT are cream or gel formulations.

The vaginal tablet comes in such a low dose that a blood estradiol level can hardly be measured with its use. “You can’t really see a change,” Dr Schiff said. Because it is a low dose, however, it is not thought to cause endometrial cancer, and combination therapy with progestin is not necessary, he said.

Although not as effective as estrogen for treating the symptoms of menopause, Replens (an over-the-counter polycarbophil-based vaginal moisturizer) confers the same benefits as estrogen in increasing vaginal moisture, fluid volume, and elasticity, he said.

For dispareunia (pain during intercourse) or vaginal dryness, a low-dose topical formulation of estrogen is appropriate, he said; vaginal dryness is a significant problem that is often unaddressed. “As obstetricians and gynecologists, it is really critical that we ask our patients about this,” Dr Schiff said.

For assessing whether to use HT for fracture prevention, Dr Schiff recommended using the World Health Organization Fracture Risk Assessment Tool (FRAX). Accessible online, FRAX offers risk calculators that help practitioners determine whether medical therapies are needed to prevent fractures in postmenopausal women, as well as in men aged ≥50 years.

A number of complementary and alternative therapies are available for menopausal women, but in most cases, there is insufficient research to prove their efficacy. According to Dr Schiff, white and Japanese women are most likely to use treatments, such as Bellergal, black cohosh, dong quai, vitamin E, evening primrose oil, ginseng, red clover, acupuncture, mind/body therapies, and yoga.

A natural aid for women with dispareunia or vaginal dryness is regular copulation, because it promotes vaginal elasticity and lubrication, he said.

Although paroxetine has been shown to reduce hot flushes, it should not be used in combination with tamoxifen because of the increased risk for breast cancer.