Menopausal vasomotor symptoms

Other Uses in Geriatric Patient Menopausal vasomotor symptoms, Alcohol withdrawal, PTSD, Excessive salivation or drug-induced sialorrhea... 

Raloxifene - does not reduce menopausal vasomotor symptoms. 

Estrogens and progestagens used for postmenopausal hormone therapy still are prescribed commonly in the United States, especially for the management of menopausal vasomotor symptoms. Even before pnblication of the WHI findings, only a fraction of women filled then-hormone therapy prescriptions, and only 25% to 40% continned to take postmenopausal hormone therapy for more than 1 year." This may be due to women s attitudes toward hormone therapy or aresnlt of fear about adverse effects and associated risks. Hormone therapy nse in the United States declined substantially after dissemination of the WHI study results." "... 

However, it is not unreasonable to assume that enzyme inducers that increase the metabolism of contraceptive steroids (see Table 28.1 , (p.975)) would also increase the metabolism of oestrogens used for HRT. Some manufacturers state that these drugs may reduce the efficacy of HRT preparations. This would be most likely to be noticed where HRT is prescribed for menopausal vasomotor symptoms, but might be difficult to detect where the indication is osteoporosis. The interaction is not relevant to HRT applied locally for menopausal vaginitis. It has also been suggested that any interaction is less likely with transdermal HRT, which bypasses hepatic first-pass metabolism. Further study is needed to confirm the importance of this possible interaction. 

UPMALIS D H, LOBO R, BRADLEY L, WARREN M, CONE F L, LAMIA C A (2000) VaSOmotor symptom relief by soy isoflavone extract tablets in postmenopausal women a multicenter, double-blind, randomized, placebo-controlled study. Menopause. 1 236-42. 

This series of trials, and many more, has led to the dramatic change in how HRT is currently prescribed and greater understanding of the associated risks. HRT, once thought of as a cure-all for menopausal symptoms, is now a therapy that should be used only to reduce the frequency and severity of vasomotor symptoms associated with menopause in women without risk factors for CHD or breast cancer. The changes that have occurred over the years in the use of HRT further support the importance of evidence-based practice and judicious medication use. 

Vasomotor symptoms, as well as other menopausal symptoms, occur in over 50% of perimenopausal women and over 80% of menopausal women.5 Menopausal symptoms tend to be more severe in women who undergo surgical menopause compared with natural menopause because of the more rapid decline in estrogen concentrations. Women who seek medical treatment should undergo laboratory evaluation to rule out other conditions that may present with similar symptoms, such as abnormal thyroid function or pituitary adenoma. Once other conditions have been excluded, HRT should be considered. 

Hormone-replacement therapy remains the most effective treatment for vasomotor symptoms and vulvovaginal atrophy and should be considered for women experiencing these symptoms. The goals of treatment are to alleviate or reduce menopausal symptoms and to improve the patient s quality of life while minimizing adverse effects of therapy. The appropriate route of administration should be chosen based on individual patient symptoms and should be continued at the lowest dose for the shortest duration consistent with treatment goals for each patient. 

Nonpharmacologic therapies for menopause-related symptoms have not been studied in large randomized trials, and evidence of benefit is not well documented. Owing to minimal adverse effects with these types of interventions, it maybe prudent for patients to try lifestyle or behavioral modifications before and in addition to pharmacologic therapy. The most common nonpharmacologic interventions for vasomotor symptoms include4,7,8... 

Estrogen currently is indicated for the treatment of moderate to severe vasomotor symptoms and vulvovaginal atrophy associated with menopause. In addition, it is indicated for the prevention of postmenopausal osteoporosis in women with significant risk however, it is recommended that non-estrogen medications receive consideration for long-term use. Oral or transdermal estrogen products should be prescribed at the lowest... 

HRT is indicated primarily for the relief of moderate to severe vasomotor symptoms. It remains the most effective treatment for vasomotor symptoms and should be considered only in women experiencing those symptoms. Women with mild vasomotor symptoms may benefit from nonpharmacologic therapy alone however, many women will seek medical treatment for these symptoms. The benefits of HRT outweigh the risks in women who do not have CHD or CHD and breast cancer risk factors however, careful consideration should be given to alternative therapies for the relief of menopausal symptoms in women with these risks. Women should be involved in the decision and may choose to use HRT despite having some risk factors owing to the severity of their symptoms. Regardless of the situation, HRT should be prescribed at the lowest dose that relieves or reduces menopausal symptoms and should be recommended only for short-term use. Women should be reassessed every 6 to 12 months, and discontinuation of therapy should be considered. 

Overall, non-hormonal therapies are less effective in treating vasomotor symptoms than HRT but do offer an important option for women experiencing menopausal symptoms who cannot or are unwilling to take HRT. The antidepressants gabapentin and clonidine have the best evidence for efficacy of all the non-hormonal options and should be considered first as an alternative to HRT. The most important considerations in choosing an alternative therapy are the patient s comorbidities and the efficacy and safety of the medication. 

Fugate SE, Church CO. Nonestrogen treatment modalities for vasomotor symptoms associated with menopause. Ann Pharmacother 2004 38 1482-1499. 

Tamoxifen is discussed in Chap. 61, Breast Cancer raloxifene is discussed in Chap. 3, Osteoporosis. Raloxifene decreases bone loss in recently menopausal women without affecting the endometrium and has estrogen-like actions on lipid metabolism. It may exacerbate vasomotor symptoms, and it increases the risk of venous thromboembolism and stroke. 

As the first SNRI drug approved, venlafaxine has become one of the first-line choices for depression and anxiety disorder [45,46]. An active metabolite, desvenlafaxine (19), is also under clinical development for the treatment of major depressive disorders [47], Preclinical studies also indicate that 19 may be effective in relieving vasomotor symptoms associated with menopause (e.g., hot flushes and night sweats) [47,48]. Desvenlafaxine is reported to be in clinical development for the treatment of fibromyalgia and neuropathic pain, as well as vasomotor symptoms associated with menopause [68]. 

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