• For Symptoms of Perimenopause
• For Osteoporosis
• For Heart Disease
• Treatment Options for All Peri- and Postmenopausal Women
• Complementary Medicine Approaches to Menopause
• Continuing Questions About Medication Treatments For Menopause

For Symptoms of Perimenopause

In addition to standard HRT, other medications may ease the symptoms of perimenopause. Herbs are discussed in the "complementary medicine" section.

1. "Extra low dose" birth control pills (e.g. Lo Estrin®) can help bridge the time between perimenopause and postmenopause to help provide contraception, regulate menses (which typically become irregular before ceasing altogether) and ease perimenopausal symptoms. Low dose pills are usually stopped around age 52 and may be replaced by ERT or HRT at that time.


2. SSRI (selective serotonin reuptake inhibitor) drugs may help with mood swings. Examples include fluoxetine (Prozac®), paroxetine (Paxil®), sertraline (Zoloft®) and citralopram (Celexa®).


3. Progestogens (e.g. Provera® and Prometrium®) taken orally may decrease hot flashes, although they can cause depression, weight gain and breast tenderness. Other new progestogens may cause fewer of these side effects. Some women choose to use over-the-counter progesterone cream for perimenopausal symptoms, although no studies confirm effectiveness here.


4. Estrogen vaginal creams have been proven to help ease vaginal dryness and loss of elasticity and may decrease problems with urinary stress incontinence (leaking during coughing or laughing).


5. Androgens (male hormones such as methyl testosterone or nandrolone) may increase libido and improve vaginal tone, but current studies do not confirm their safety and efficacy.


6. Clonidine is a blood pressure medication occasionally prescribed for hot flashes. It has been shown to decrease hot flashes for up to 8 weeks in women with breast cancer who are taking tamoxifen, a drug with anti-estrogen effect.


7. Vaginal lubricants (many kinds, over the counter) may ease vaginal dryness.

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For Osteoporosis

1. Bisphosphonates include alendronate (Fosamax®), residronate (Actonel®), and etidronate (Didronel®). These drugs prevent bone reabsorption or loss and are prescribed to prevent or treat osteoporosis. They must be taken on an empty stomach and can cause esophageal irritation. These drugs stay in bone permanently and no studies on long-term safety have been completed. Estrogen taken along with a bisphosphonate may provide added benefit to bone density.


2. Raloxifene (Evista®) appears to help build bone slightly in early postmenopausal women, but not as well as estrogen or alendronate. Raloxifene is in a class of drugs called selective estrogen receptor modulators (SERMs). Different SERMs appear to vary in their estrogen promoting and estrogen inhibiting effects on different tissues. Potential benefits of raloxifene are not yet confirmed, nor are the risks of long-term use. Raloxifene may be especially promising for women at higher risk of breast cancer, because the drug suppresses growth of breast cancers and has favorable effects on serum cholesterol. It can also worsen hot flashes.


3. Calcitonin (Miacalcin® injection or nasal spray) is a salmon-based version of a hormone secreted by the parathyroid gland. It inhibits bone reabsorption and slightly increases bone density. Tested primarily in women who already have osteoporosis, it also prevents bone loss. It also may decrease pain from osteoporotic fractures. No studies on long-term safety are complete. Other forms of parathyroid hormone may become available in the next few years.


4. Fluoride. Short-acting preparations are no longer used because they did not consistently decrease fracture rate. New slow-release preparations may be safer but efficacy is not yet confirmed.

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For Heart Disease

The WHI and HERS studies do not support using HRT to prevent coronary heart disease in women with or without a history of prior heart disease. Heart disease prevention should focus first on healthy lifestyle. Medications may be necessary to treat risk factors such as hypertension, diabetes and adverse serum lipids (e.g. elevated LDL cholesterol and triglycerides and low HDL cholesterol). Because the incidence of heart disease in women rises sharply after menopause, cholesterol screening for women typically begins at perimenopause.


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Treatment Options for All Peri- and Postmenopausal Women

Lifestyle Enhancement:

Common-sense advice for everyone includes: do not smoke, do exercise (a good goal is 30 minutes every day, but every bit helps), correct visual and/or hearing problems and lose excess weight.

Healthy diet:

Increase Consumption of :	Decrease Consumption of :
Antioxidant foods (fruits + veggies)	Alcohol (keep to less than 1 drink/day average)
Fiber	Soft (carbonated) drinks
Soy (beans, tofu)	Animal protein
Omega-3 fatty acids (many fishes, grains, beans, tofu)	Saturated and polyunsaturated fats (butter, cottonseed oil)
Calcium-rich foods (non-fat milk, yogurt)	Caffeine

Vitamin and mineral supplements for bone health

Vitamin D: 200 IU daily until menopause, then 400 IU daily to enhance calcium absorption and bone retention. This is particularly important for housebound people with little exercise or sun exposure. Note that sunscreens block the synthesis of Vitamin D in skin.

Calcium: Women aged 25-50 who have not gone through menopause should have a calcium intake of 1000 mg daily. After menopause, a calcium intake of 1200 mg per day is still recommended for women, whether or not they are taking hormones.

Vitamins as antioxidants

Free oxygen radicals are byproducts of metabolism that are implicated in several diseases of aging. Various antioxidants are proposed to neutralize free radicals. The quality of studies investigating these agents varies, so the benefits and optimum doses are not well confirmed. Moderate doses are recommended, and many of these can be found in a single daily multivitamin.

Vitamin E (400 IU/every other day)

Vitamin A (5000 IU daily)

Vitamin B complex (including folate, 1 mg daily, and niacin, 100 mg daily) may decrease mood disturbances of peri- and postmenopause. Higher doses of niacin can worsen hot flashes.

Vitamin C (best dose is unknown; the U.S. recommended daily allowance is approximately 80 mg). When used with calcium supplements, high doses of Vitamin C may precipitate kidney stones. Doses over 1000 mg are not recommended.

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Complementary Medicine Approaches to Menopause

There are many complementary medicine disciplines active in the United States: naturopathy, Chinese medicine, homeopathy, chiropractic and acupuncture, to name a few. Some of practitioners of these disciplines are state licensed (e.g. acupuncture and chiropractic in California). They often combine body work (such as acupuncture, chiropractic or "energy" work) with herb supplements. In this context, "herbs" means plants used as medicines that are available without prescription. Few rigorous scientific studies have been done on herbs, and doses and preparations are not standardized. Herbs are not regulated by the U.S. Food and Drug Administration and so are not required to be proven effective. Use herbs cautiously; always get their names and contents and discuss them with your clinician.

1. Plant estrogens (known as phytoestrogens) were first discovered in 1946, when sheep grazing on red clover became infertile. Phytoestrogens are found in soybeans, yams, peas, papayas, cucumbers and black cohosh. Women eating 1 to 3 cups of tofu or 1/4 to 1/2 cup of soy nuts daily have lower total cholesterol and triglycerides and fewer breast cancers. However, studies have not confirmed that the phytoestrogens in soy, called isoflavones, account for these good outcomes.


2. Progesterone is found in wild yams (sometimes called "natural" progesterone) and has been added to skin creams. Little of this progesterone may be absorbed when eaten, and absorption through the skin is hard to confirm. Progesterone creams should not be confused with "natural" progesterone pills available only by prescription (e.g. Prometrium®). Studies have conflicting results about whether progesterone creams reduce menopause symptoms.


3. St. John's wort is an herb available without prescription. It has been shown to be more effective than placebo for mild depression. It is being studied for this purpose in comparison to SSRI drugs, but it has been shown to be ineffective for major depression. St. John's wort can interfere with metabolism of other drugs. It may increase blood pressure and cause extra sensitivity to sunburn.


4. Kava is a root that has been suggested for anxiety or insomnia. But this drug has a poor safety profile and may cause irreversible liver damage.


5. Black cohosh is a root available in the United States as Remifemin®. Several studies have shown black cohosh to reduce hot flashes when compared to either placebo or other treatments. The active ingredient is not known. No long term studies on safety or efficacy have been conducted.


6. Red clover has not demonstrated benefit in decreasing hot flashes or vaginal changes of menopause.


7. Don Quai is a root typically available in mixtures with other herbs. Although reported to have an estrogen-like effect, studies do not show any benefit for hot flashes or vaginal menopause changes. It may increase bleeding tendencies.


8. Vitamin E is not effective in treating menopause symptoms, when compared to various other preparations.


9. Acupuncture does not reduce hot flashes or sleep disturbance in menopause.


10. Behavioral therapies: Paced respiration (slow, deep breathing) decreased hot flashes in several studies; relaxation response technique decreased intensity but not frequency of hot flashes in one study.

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Continuing Questions About Medication Treatments For Menopause

The more we study, the more we learn and the more questions arise, including the following:

1. What is the best dose or regimen for a medicine? Many studies do not compare different doses or ways of taking the medication under study. We presume that the lowest dose necessary for a desired benefit is best.


2. When to start treatment? If a woman has few risk factors, why not wait until she is older to start therapies to prevent illnesses of advanced age? Are women ever too old to start medications?


3. When (if ever) to stop treatment? For example, the benefits of medications to build bone density may be lost after treatment is stopped, so treatment for osteoporosis is recommended lifelong. But we have no studies on the long-term safety of these drugs.


4. Are "natural" or newer synthetic hormone choices safer and/or more effective? How important is it to supplement with the exact substance made by the human body (e.g. progesterone) versus a substitute (e.g. Provera®)? In the case of estrogen, the type of estrogen made naturally by the body changes through menopause (e.g. less estradiol, more estrone), so which one(s) should be replaced? Will different dosing schedules (e.g. alternating days of medication) be safer and/or more effective?

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