Yesterday’s issue of the New England Journal of Medicine had a very helpful review article: Management of Menopausal Symptoms. (The full text is available even to non-subscribers.) The article reviews the existing evidence about the prevalence of symptoms related to menopause and the risks and benefits of various treatments. I summarize the article below.
The symptoms most associated with menopause are vasomotor symptoms (hot flushes and night sweats), vaginal symptoms, and trouble sleeping. About 65% of women have hot flushes during menopause. In most women, the hot flushes resolve within 4 to 5 years. Vaginal symptoms, including dryness, discomfort, itching, and discomfort during intercourse, are reported by about half of women during menopause. Unlike hot flushes, these symptoms do not resolve with time, and they sometimes worsen. Vaginal symptoms are most effectively and safely treated with vaginal estrogen cream.
A great number of treatments have been used for vasomotor symptoms, many without strong evidence. Many women find relief with simple measures such as dressing in layers and lowering the temperature of their room. In regard to the many alternative medications used for hot flushes, the author states:
There is no convincing evidence that acupuncture, yoga, Chinese herbs, dong quai, evening primrose oil, ginseng, kava, or red clover extract improve hot flushes. One trial of vitamin E found a statistically significant effect, but the benefit was only one hot flush per day less with treatment, as compared with placebo. Evidence regarding black cohosh is mixed but primarily negative.
Estrogen has been proven to improve hot flushes, but it has also been proven to increase the risk of stroke (a risk I wrote about in April). Antidepressants have also been tested with mixed results. Gabapentin (Neurontin) is modestly effective but has some bothersome side effects. Most expert groups therefore recommend that if a woman is having severe enough hot flushes that simple environmental measures (i.e. dressing in layers, cooling the room) don’t bring relief, the lowest dose of estrogen necessary to relieve the symptoms be used. (Progesterone should be added in a woman who has not had a hysterectomy.) The woman should understand the potential risks of estrogen and that her hot flushes will likely resolve in a few years. Attempts should be made every 6 months or so to wean off the estrogen, thereby attempting to use the lowest dose of estrogen for the shortest duration necessary.
Two patients pointed out to me the two recent studies and the editorial in the New England Journal of Medicine regarding the use of epoetin (or EPO, marketed under the brand names Procrit and Epogen) in patients with kidney disease. The Los Angeles Times published an article that covered the issue well. If you or someone you know takes EPO, please read these articles and discuss them with your doctor.