Menopause: A Stepwise Approach to Relief

The intensity, duration, and type of symptoms a women experiences during menopause depends on a variety of factors. Pharmacists are in a position to identify appropriate strategies to reduce or manage the most bothersome symptoms.

Many women experience uncomfortable symptoms as they approach menopause. The hallmark symptom is the hot flash (also called the hot flush). This sudden feeling of intense warmth in your face and chest is followed by skin redness (flushing) and heavy sweating. Then it ends with a cold, clammy feeling. Some women may also have fast heartbeats (palpitations), a feeling of pressure in the head, dizziness, faintness, or weakness. A hot flash usually lasts from 1 to 5 minutes. Approximately 80% of women suffer from hot flashes before, during, and after menopause. Hot flashes usually occur for 2 to 5 years before they taper off, but can last longer. Some women may never have a hot flash and some may have them for many years.

What is Happening to Me?

Until menopause, your ovaries release eggs during every menstrual cycle—this is called ovulation—and you can become pregnant. Your ovaries also make most of your body’s estrogen. As you get older— usually as you approach age 45 to 50— your ovaries gradually stop producing as much estrogen. This usually begins when women are in their mid-to-late 40s. When your estrogen levels fall low enough, menstrual periods stop. Menopause may also occur if you have had your ovaries surgically removed; or if they have been damaged by radiation or chemotherapy; or if you take medicine that lowers your estrogen levels. Hot flashes that happen at night are called “night sweats,” and it can feel as if they disrupt your entire life. They may wake you, and the cold feeling when they are finished may keep you awake.

Most women have their final menstrual period at about age 50 or 51. We say that a woman has reached menopause when she has not had a menstrual period for 12 months in a row. Ovulation stops and you will no longer be able to become pregnant.

What Symptoms of Menopause Are Most Bothersome?

Many people call menopause the “change of life.” As you start to enter menopause in your mid 40s, you may begin to notice hot flashes and other changes in your body. As estrogen levels fall, every woman experiences different symptoms. Some lucky women have no symptoms whatsoever, but others have troublesome symptoms. Some things that seem to make symptoms more severe include family history, having started your periods at a young age, smoking, poor diet, a higher body mass index (BMI) than is ideal, lack of exercise, and your ethnic heritgage (African American women seem to have more hot flashes than others).

The most common symptoms of menopause are:

• Bladder problems
• Hot flashes
• Mood swings
• Night sweats
• Severe tiredness
• Sleep problems
• Stiff painful joints
• Vaginal dryness

These symptoms may disappear within a few months, but sometimes they can persist for several years after the last menstrual period.

As women age, they are at increased risk of developing other health conditions—this is natural. It’s at this time of life that some women develop heart disease, dryer skin, and lack of interest in sex. These problems can be related to low estrogen levels. Low estrogen after menopause can also cause faster bone loss and increase your risk of developing osteoporosis (“brittle bones”). If you have any of these specific problems, talk to your doctor or pharmacist.

Short of Taking Medicine, What Can I Do to Deal With My Symptoms?

The best approach to reducing menopause symptoms is to look at your lifestyle and make simple changes.

• Many women note that certain things bring on hot flashes, or make them worse. These are called “triggers.” Pay attention to what is happening before and during your hot flashes. Once you identify things that cause or contribute to your hot flashes, you can avoid them. You may find that hot drinks, hot or spicy foods, alcohol, caffeine, cigarette smoking, stress, hot weather, or a warm room may trigger a hot flash.
• Exercise regularly. Exercise reduces stress, decreases your risk for heart disease and diabetes, helps you preserve your bones, and can help you get a better night’s sleep.
• If you are overweight, try to shed a few pounds. Lighter women seem to have fewer symptoms.
• Stay as cool as you can. Dress in layers so that you can remove clothing quickly to cool off. Use a fan or air conditioner to keep the air around you cool.
• Use layered bedding, and throw off part or all of your covers when the night sweats begin. Keep cool water at your bedside to sip if you awaken during sleep, or get up and run cool water on the insides of your wrists.
• Learn to control your breathing. Practice taking slow, deep, rhythmic breaths.
• If you smoke or drink alcohol more than just socially, consider stopping.

At What Point Might I Consider Drug Therapy and What Are the Options?

If you are unable to make the lifestyle changes listed above, or you do and your symptoms are still troublesome, you may consider trying medication. Because symptoms of menopause are caused by decreasing estrogen, one approach is to replace the estrogen you are losing.

Estrogen therapy, called ET, is the most effective treatment for menopausal symptoms. Sometimes, ET is given as tablets or capsules that you take by mouth, but it can also be given as a patch or a ring that is placed in your vagina. If you still have a uterus (it hasn’t been removed by hysterectomy), your doctor may give you progestin with estrogen. And, if you are sexually active, your doctor may prescribe oral contraceptives, because they contain estrogen, too.

There has been a lot of publicity about estrogens lately based on some research studies that showed that estrogens increase the chance of getting cancer of the uterus and may increase the risk of heart trouble, especially in older women. Because of this, your doctor will prescribe estrogens at the lowest dose possible for your treatment and only as long as needed. Pharmacists who dispense estrogens will always include written information with your prescription. Be sure to read it carefully before you start taking estrogens.

Your doctor might also suggest trying a drug called a selective serotonin/ norepinephrine reuptake inhibitor. These drugs were originally developed to treat depression, but also seem to reduce the number and severity of hot flashes for many women. They may also help if you have problems with irritability or mood swings. Side effects of these agents may include headache, dry mouth, nausea, difficulty sleeping, and sexual dysfunction.

Some women turn to complementary and alternative medicine therapy, or “herbal treatments,” for relief. There is no proof that any of the most popular remedies—plant-derived phytoestrogens from soy supplements, black cohosh, or vitamin E—are effective. For some women, they may offer some relief, however.

If I Decide to Use Medicine to Address My Symptoms, What Do I Need to Know?

You should never use estrogens if you have unusual vaginal bleeding, currently have or have had certain cancers, have had a stroke or heart attack in the past year, or have blood clots or liver problems. You should also avoid estrogens if you think you may be pregnant. You should use any medicine for menopausal symptoms at the lowest dose possible to get relief and only as long as needed. Read all of the written material when you fill your prescription, and call your doctor or pharmacist if you have questions. PT

Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Maryland. The views expressed are those of the author and not those of any government agency.