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Treatment optionsSymptoms stemming from perimenopause,menopause or postmenopause are subjective. Some women may sail through menopause without any symptoms,as more substantial changes take place within their bodies. For other women,the transition may be a challenging phase in their life,especially when their roles in their family are changing.
Several safe strategies are available to help alleviate symptoms caused by fluctuating or declining levels of or deficiency of oestradiol,depending on the woman’s stage in the menopausal transition. However,there is no complete cure. There is no specific hormonal formulation designed for women in the perimenopausal period,wherein the goals of hormonal treatment are to regulate the menstrual cycle,provide safe contraception and offer relief from distressing symptoms.
MHT and antidepressants have both been used for menopause-related VMSs with good results. Although MHT is considered the gold standard treatment for VMSs and the GSM,it is known to be linked to an increased risk of oestrogen-dependent pathologies,such as breast and endometrial cancers,cardiovascular disease and thromboembolism. Therefore,clinicians must first assess patient-specific risks and benefits,which must be discussed with every patient on an individual basis. Women who are experiencing hot flashes but are unable to take hormone replacement therapy (MHT) or prefer alternative options often turn to non-hormonal therapies to manage the frequency and severity of VMSs. These non-hormonal therapies may include both non-pharmaceutical and pharmaceutical options.
i) Non-hormonal therapy may be instituted when MHT is contraindicated. Serotonin receptor inhibitors such as SSRI or selective norepinephrine receptor inhibitor,gabapentin and pregabalin have yielded improvements of VMSs by up to 50%-60%.
ii) Pelvic floor physical therapy and bladder training are useful adjuvant measures for urinary incontinence.
iii) Nutrition,exercise and other lifestyle measures
In an 8-year prospective study conducted on Finnish women,the role of physical activity on the QoL among menopausal women was studied.,Although the menopausal transition was not significantly correlated with changes in the global QoL,the study highlighted the importance of increased physical activity and supported the hypothesis that menopause may provide a ‘window of opportunity’ for counselling by v) general practitioners to induce lifestyle modification. General practitioners should take cognisance and proactively work with preventive and lifestyle measures,such as a balanced diet,exercise regime,smoking and alcohol drinking cessation and relaxation therapy,rather than expect women’s condition to improve spontaneously when symptoms resolve.
iv) Cognitive behavioural therapy (CBT) for women with low mood
CBT has been used as a useful tool for a range of health-related problems in the perimenopausal period,including hot flashes,depressed mood,sleep problems and stress. Relaxation and paced breathing are employed to calm the body’s physical and emotional reactions. Yoga,breathing exercises and meditation have effectively reduced physical and psychosocial symptoms. Life stresses,the empty-nest syndrome,disability or death of a spouse are additional stresses that compound menopausal symptoms,leading to anxiety—depressive illness and difficulty in coping with day-to-day living.
A comprehensive and holistic approach is necessary to effectively manage these issues. Loss of sleep,excessive consumption of caffeine,nocturia,age-related pelvic organ prolapse and urinary incontinence need careful evaluation and cause-focused therapy. Stress,caffeine consumption and smoking can worsen mastalgia. Many women mistake these symptoms as part of serious diseases and waste much time,energy and money pursuing ineffective remedies,with work impairment and unnecessary healthcare utilisation. In cases of sexual dysfunction,marital and sexual therapies and counselling can be implemented. Promoting healthy lifestyle and addressing negative attitudes about the menopausal transition through educational interventions should be strongly encouraged. Good nutrition,physical activity such as brisk walking for a minimum of 150 minutes per week,cessation of smoking and reduction of alcohol intake should also be highlighted,as these would benefit women of all ages.
v) MHT
In the menopausal transition,cyclical hormone therapy can be prescribed if regular menstrual bleeding is desired. Treatment should be individualised on the basis of patient and risk factors,and a non-oral oestrogen is often preferred. Oestrogen—progestogen therapy (EPT) in the form of oral contraceptives and combination therapy with intrauterine levonorgestrel and oral/percutaneous oestrogen (LNG-IUS plus oral/ percutaneous oestrogen) have been commonly used. Ten to fourteen days of progestogen therapy can be added to MHT if the patient has not undergone hysterectomy. The shortest duration of therapy is typically prescribed,aiming to discontinue MHT within 3—5 years. A tailing-off period of 6 months is advised when MHT is to be terminated.
MHT is the most effective treatment for VMSs associated with menopause. Its benefits outweigh the risks for symptomatic women,provided it is administered within 10 years after the diagnosis of menopause and within 60 years of age. The use of MHT in symptomatic women during this ‘window of opportunity’ significantly counteracts the ageing process at many target organs. MHT is contraindicated in patients with breast cancer. Oral oestrogen is associated with an increased risk of venous thromboembolism (VTE). Transdermal oestrogen and vaginal rings are preferrable for women who have an increased risk of VTE (i.e. smokers or obese women). Selective serotonin receptor inhibitors,selective norepinephrine inhibitors,gabapentin and pregabalin are alternatives when MHT is contraindicated.
Unless treated,urogenital atrophy persists after menopause. The GSM,previously known as atrophic vaginitis or vulvovaginal atrophy,is caused by low levels of oestrogen. It affects more than 50% of postmenopausal women,mostly causing urinary problems and sexual dysfunction. Low-dose over-the-counter vaginal oestrogen cream is safe and effective. It is the mainstay treatment when symptoms are limited to vaginal dryness,discomfort or dyspareunia. However,this should be avoided in survivors of hormone-sensitive cancers.
Although MHT prevents bone loss and fractures,it is not specifically prescribed for the prevention of osteoporosis.
Women should be prescribed MHT after informed consent is obtained,and evaluation is performed for its suitability. Doctors must document patients’ deliberated reasons for considering MHT (ET/EPT) (e.g. QoL or severity of symptoms) as well as consideration of risks and benefits of short-term ET/ EPT use. Once started,the regimen should be reviewed annually to justify safe continuation of MHT to within 10 years after menopause. In most instances,MHT should be prescribed for 2-3 years and reviewed for extension of use to up to 5 years. Long-term use needs thorough review of risk factors.
vi) Progesterone-only regimen
Although the levonorgestrel-releasing intrauterine device (LNG-IUD) can suppress the endometrium while providing contraception,it is particularly helpful for managing cases of heavy bleeding. Although initial breakthrough bleeding may occur,80% of women become amenorrhoeic after 1 year. The LNG-IUD can be combined with oral or transdermal oestrogen and left in situ for 5 years. However,the LNG-IUD alone will not stop vulvar and vaginal changes or VMSs. When oestrogen is not tolerated,oral medroxyprogesterone 10 mg daily can be administered to alleviate VMSs.
The Women’s Health Initiative Study employed treatment with medroxyprogesterone 2.5 mg daily and showed an excess risk of coronary heart disease and breast cancer. Micronised progesterone taken at bedtime reduces sleep disturbance and is safer for the cardiovascular system. If hysterectomy has been conducted,progestogen is not prescribed. There are controversies that the progestogen component in MHT increases the incidence of breast cancer. The selection of cases and duration of therapy with newer micronised progestins have been successful with the safe use of this hormone.
vii) Combined oral contraceptive pills (COCPs)
COCPs not only provide contraception and menstrual cycle control but also offer relief from VMSs and other symptoms. Low-dose ethinyloestradiol OCP (20 pg) or oestradiol-containing OCP is preferred. However,each woman’s risks in using COCPs must be assessed individually. Detailed history-taking must exclude risks such as smoking,coexisting high blood pressure or cholesterol level,liver disease,migraine with aura,history of thrombosis,epilepsy and family history of breast cancer. Third-generation oral contraceptives are recommended for smokers and women aged above 35 years if there are no other risk factors for thrombotic arterial disease. VMSs in the pill-free week can be managed by discarding the placebo tablets or adding a low dose of oestrogen. When contraception is no longer needed,the woman can transition from COCP therapy to MHT.
Continuous COCP therapy is required when menopausal symptoms are experienced during pill-free days when low-dose oestrogen-containing COCPs are prescribed. This therapy may be prescribed after good case selection and case screening.
viii) Selective oestrogen receptor modulators (SERMs) and vaginal dehydroepiandrosterone
SERMs and vaginal dehydroepiandrosterone are newer treatment options that can also be considered. The combination of bazedoxifene with conjugated oestrogen has been shown to be effective for treating VMSs in women who cannot tolerate the side effects of progestogen (e.g. bloating and breast tenderness). However,similar to other SERMs,bazedoxifene is associated with an increased risk of deep vein thrombosis.
ix) Tibolone
Tibolone is a synthetic steroid that is not as effective as oestrogen in reducing VMSs. Nevertheless,it has beneficial effects on bone mineral density and sexual dysfunction. Recurrence of breast cancer and stroke (>60 years) are its known complications.","department":"
