Vasomotor symptoms, in menopause

Other climacteric symptoms include disturbances in the menstrual pattern, palpitation, headache, dizziness, numbness, myalgia, vaginal dryness and urinal tract symptoms. In over half of the climacterically symptomatic women also mental symptoms, such as anxiety, depression, decline in libido, lack of concentration, and memory impairment, are present these can exceed the severity of vasomotor symptoms. Further, sleeping problems are frequent during menopausal transition. They may show as exclusive symptoms or in addition to other climacteric symptoms. They are often attributed to nocturnal vasomotor symptoms. In menopausal women vasomotor symptoms are reported in 65-85 %, mental symptoms in 50-80 % and sleeping problems in 50-80% [23, 24], The duration of the symptoms has a wide variety. Vasomotor symptoms are experienced for 1-2 years in most of the women, but about 25 % will experience them for 5 years and even 9 % practically all lifelong [25, 26]. 

Utian WH. Psychosocial and socioeconomic burden of vasomotor symptoms in menopause a comprehensive review. Health and Quality of Life Outcomes 2005 3 47-56. 

It is indicated in hypertension of all grades except pheochromocytoma, glaucoma and migraine. It is also useful in opiate, alcohol and nicotine withdrawal. It also attenuates vasomotor symptoms of menopausal syndrome. 

Some of the growth in antidepressant use may be related to the broad application of these agents for conditions other than major depression. For example, antidepressants have received FDA approvals for the treatment of panic disorder, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). In addition, antidepressants are commonly used to treat pain disorders such as neuropathic pain and the pain associated with fibromyalgia. Some antidepressants are used for treating premenstrual dysphoric disorder (PMDD), mitigating the vasomotor symptoms of menopause, and treating stress urinary incontinence. Thus, antidepressants have a broad... 

The SNRIs include venlafaxine, its metabolite desvenlafaxine, and duloxetine. Another SNRI, milnacipran, is in late clinical trials in the USA but has been available in Europe for several years. In addition to their use in major depression, other applications of the SNRIs include the treatment of pain disorders including neuropathies and fibromyalgia. SNRIs are also used in the treatment of generalized anxiety, stress urinary incontinence, and vasomotor symptoms of menopause. 

Burke GL, Legault C, Anthony M, et al. Soy protein and isoflavone effects on vasomotor symptoms in peri- and postmenopausal women The Soy Estrogen Alternative Study. Menopause 2003 10 147-153. 

The decline in ovarian function at menopause is associated with vasomotor symptoms in most women. The characteristic hot flashes may alternate with chilly sensations, inappropriate sweating, and (less commonly) paresthesias. Treatment with estrogen is specific and is fhe most efficacious pharmacotherapy for these symptoms. If estrogen is contraindicated or otherwise undesirable, other options may be considered. 

Vasomotor symptoms The decline in ovarian function at menopause is associated with vasomotor symptoms in... 

Burke, G.L. C. Legault M. Anthony D.R. Bland T.M. Morgan M.J. Naughton K. Leggett S.A. Washburn M.Z. Vitolins. Soy protein and isoflavone effects on vasomotor symptoms in peri- and postmenopausal women The soy estrogen alternative study. Menopause 2003, 10, 147-153. Calder, P.C. R.F. Grimble. Polyunsaturated fatty acids, inflammation and immunity. Eur. J. Clin. Nutr. 2002, 56, S14-19. 

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. 

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. 

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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