By Angela Keating, M.D., board-certified obstetrician/gynecologist with Providence Women's Clinic, Providence St. Vincent Medical Center
The end of monthly periods, a potentially liberating life change, can be the beginning of a whole new set of problems for many women. Hot flashes, night sweats, insomnia, mood swings, brain fog, decreased libido, vaginal dryness, painful intercourse…you might not experience all of these menopause symptoms, but even a couple of them can make you pretty miserable.
If your symptoms are getting in the way of enjoying your life, one of the most important things you can do is to connect with a skilled health care provider. There are a lot of effective options for managing menopause symptoms, but finding what works for you may take some time. A trusted health care partner can help guide you toward the best options for your unique body and preferences.
Hot flashes and night sweats
Of all the changes women may experience during menopause, hot flashes and night sweats are the most common – about 80 percent of women experience them. For some, they’re only a mild and temporary nuisance. But for others, they can be pretty distressing, and can cause or worsen other problems, including insomnia and depressed mood. Treating the hot flashes and night sweats may bring relief from these other problems, as well.
Hormone replacement therapy, or HRT, is still considered a safe and effective choice for many women whose hot flashes, night sweats and other symptoms are intolerable. However, it’s not right for everyone, and many other choices are available. Here is an overview.
Hormone replacement therapy
As with any medication, there are pluses and minuses to taking hormones. Studies have shown that hormone replacement therapy slightly increases the risk of heart disease, stroke, breast cancer and blood clots over time. For young, healthy women without other heart or breast cancer risk factors, however, the overall risk is low. Your individual risks and benefits depend on your age, your symptoms, the type of HRT you take, your family history and your personal health and circumstances. Talk with your provider about all of these to decide whether HRT is appropriate for you.
Estrogen is the hormone in HRT that helps relieve hot flashes and night sweats. Because estrogen also can increase the risk of uterine cancer, it is usually paired with another hormone, progestin, which protects the uterus against this effect. Women who’ve had a hysterectomy don’t need progestin – they can take estrogen-only HRT.
Regardless of which form of HRT you choose – and there are many – the safest approach is to use the lowest dose for the shortest time necessary to manage your symptoms. The risks of HRT are lower in women who take it closer to the onset of menopause, before age 60. The older you get and the longer you are on hormones, the more the risks increase, so as you approach 60, it’s a good idea to start looking at tapering off of HRT. For women with severe, ongoing symptoms, it may make sense to stay on hormones, but it’s still wise to review the pros and cons with your health care provider each year to reassess what’s best for you.
Pills, patches, gels and rings: to minimize the risks associated with HRT, most doctors recommend trying a patch, gel or vaginal ring before trying a pill. All forms of HRT carry risks, but only the pill form goes through your liver, where blood-clotting factors are made, so it carries a higher risk of clotting than the non-oral methods.
- Patches – these come in several dosages and can be changed either once or twice a week. They keep your hormone level very steady.
- Vaginal rings – these can be placed and removed on your own once every three months. Like patches, they keep hormone levels very steady.
- Gels – several types of topical estrogen gels are available; you simply rub the gel on your arm or leg daily. Hormone levels fluctuate a little more with gels than with patches or rings.
- Pills – if non-oral routes don’t work for you, hormone pills may still be an option. To minimize risks, take the lowest dose that works for you.
While some pills and patches combine estrogen and progestin, many HRT products are estrogen only. Unless you’ve had a hysterectomy, that means you also need to take progesterone or progestin to counteract the effects of estrogen on your uterus (synthetic progestins are similar to the progesterone that your body makes). Progesterone or progestin pills offer easy dosing flexibility and can be used in combination with any form of estrogen.
“Natural,” bioidentical and compounded estrogens: the “natural” label used in advertising can be misleading and doesn’t have a specific medical meaning. “Bioidentical” means that the hormones in a product are identical to the ones made by your body; no study has found bioidentical estrogens or progesterone to be any better or less risky than other forms of estrogen or progestin. Products that are made up at compounding pharmacies are not as batch regulated as commercial prescriptions; however, they can be useful in some cases, when no existing prescription hormone product works for an individual.
Birth control pills: birth control pills can help relieve symptoms during perimenopause – the time before menopause when you’ve started having symptoms, but haven’t completely stopped having periods. However, once you’re in full menopause, it’s important to switch to a lower-dose therapy. The hormone dosage in HRT is about 20 to 25 percent of the levels in birth control pills, so it’s less risky.
For women who can't or prefer not to take hormone therapy, a few non-hormonal medicines can provide effective alternatives. Each comes with its own potential side effects, so they aren’t perfect, but one of these may be helpful if you have intolerable hot flashes and night sweats:
- Gabapentin: this anti-seizure medication has proven to be just as effective as estrogen in managing menopause symptoms, and is used commonly for this purpose. Drowsiness is a common side effect, so it’s best to take it at bedtime.
- Antidepressants: A low-dose form of paroxetine (Paxil, Pexeva) has been approved by the FDA to treat hot flashes. Another antidepressant, venlafaxine (Effexor XR, Pristiq), also relieves menopause symptoms. Potential side effects of these are weight gain and decrease in libido.
- Clonidine: this medicine, usually prescribed for high blood pressure, is used only rarely for hot flashes due to its blood-pressure-related side effects (headache, lightheadedness). However, it is an option for women who can’t find any other relief.
Finding the right medication and dosage may take several attempts, so don't be discouraged if the first thing you try doesn't work out.
Behavioral approaches, botanicals and basic measures
While the following approaches haven’t been proven to be effective, they don’t cause harm, and some women swear by them, so they may be worth looking into if you’re struggling:
- Botanical therapies: soy, flaxseed and black cohosh supplements often are suggested as remedies for menopause symptoms, because they contain phytoestrogens – plant-based compounds that act like natural estrogen in the body. The research doesn’t seem to show any advantages, but some women do report feeling better when they try them.
- Behavioral therapy: cognitive behavioral therapy shows potential for helping women manage several symptoms of menopause, including hot flashes, anxiety and insomnia. Hypnosis is another behavioral approach that may be helpful. Studies of both approaches are continuing.
- Reducing hot-flash triggers: alcohol, tobacco, caffeine, stress, hot foods, hot drinks and spicy foods can trigger hot flashes in many women. Everyone is different, but paying attention to these common triggers might help you identify and reduce your own.
- Yoga, exercise, mindfulness: while these health-promoting activities haven’t been proven definitively to relieve menopause symptoms, meditation, yoga, regular exercise, stress management, healthy diet and adequate rest do make you feel better in all kinds of ways. And when women feel better, they often find that they have fewer hot flashes.
Beyond hot flashes: managing other menopause symptoms
Problems falling asleep or staying asleep seem to grow more common in midlife, and may be related to menopause symptoms, to aging in general, or to some combination of the two. If hot flashes and night sweats are waking you up all night, HRT or gabapentin can help quell those. Gabapentin has the added benefit of causing drowsiness, so it improves sleep two ways. Getting back to good sleep basics – such as avoiding alcohol, caffeine, big meals and exercise right before bedtime – is worthwhile, too. For more sleep advice, read Menopause and sleep…or not.
Vaginal dryness and painful intercourse (dyspareunia) may be as uncomfortable to talk about as they are to experience, but they are very common problems. It’s estimated that about a third to half of all women in perimenopause and menopause experience these problems. So let’s talk about what can help:
- Communication: the first thing to do is to work with your partner to understand your changing body and your needs.
- Lubrication: over-the-counter lubricants don’t treat vaginal atrophy, which is the thinning, drying and inflammation of the vulvar and vaginal tissue that can lead to pain during intercourse; but lubricants can help relieve the discomfort of dryness. Pharmacies carry a variety of water- and silicone-based lubricants and oils – with a little trial and error, you may find one that works for you.
- Vaginal estrogen: if vaginal dryness and dyspareunia are your only menopausal symptoms, low-dose vaginal estrogen is a safer choice than systemic HRT. Vaginal estrogen delivers estrogen just where you need it, with very little systemic absorption (in most studies, hormone levels in the blood don’t rise above the menopause range). It is available in vaginal creams, tablets, suppositories or rings.
- DHEA: this hormone, which plays a role in libido and in estrogen production, was approved by the FDA in 2016 to treat vaginal atrophy. It is available as a vaginal suppository.
- Ospemifene (Osphena): this medication, approved by the FDA for menopausal women with vaginal dryness and dyspareunia, is part of a class of drugs called SERMs, or selective estrogen receptor modulators. It is a pill that works systemically and carries a very low risk of blood clots.
- Physical therapy: physical therapists who specialize in pelvic issues have many tools and techniques that can improve dyspareunia for some women.
- Laser therapy: CO2 lasers are currently being marketed to “rejuvenate” the vagina, but there isn’t enough information yet to evaluate their effectiveness or safety. Studies are currently in progress – it would be a good idea to wait for study results to verify their safety and long-term effectiveness.
In addition to the approaches listed above, some women ask about testosterone to increase their libido. Testosterone is not available commercially for women, but it can be purchased through compounding pharmacies. If you decide to try this, be sure to have your testosterone levels checked before and after starting it to make sure these hormone levels aren’t increasing too much.
Age-related and menopause-related changes hit women with a double-whammy that can make weight management a major challenge in midlife. Sadly, there is no magic fix for this. It still comes down to the basics – just more of them. At this time of life, women have to work harder just to maintain our weight without gaining. That means paying even more attention to eating right and to getting regular physical activity, including both aerobic and muscle-strengthening exercise.
Mood changes and anxiety
Menopause itself doesn’t cause mood changes, but it can worsen existing issues. If you notice worsening mood swings or anxiety along with other menopausal symptoms, then hormones may be beneficial. If mood issues are your only symptoms, then antidepressants or antianxiety medications may be more appropriate. The idea is to choose the medication most targeted to your specific symptoms, unless you have multiple symptoms that can be improved with a single medication.
Memory changes and brain fog
Menopause has not been directly connected to changes in memory or the ability to think clearly. But the symptoms that go along with menopause, such as hot flashes and night sweats, can certainly get in the way of a good night’s sleep, which can leave you feeling foggy. Getting menopause symptoms under control may help clear some of the fog.
Help is out there
Mild menopause symptoms may need no intervention. But if you suffer from severe symptoms and you don’t get them under control, it can be hard to function well in your life.
If you’re not doing well, talk to a doctor. It is absolutely OK to explore your options and take action to be functional and happy. It will take some detailed conversations and some trial and error, but help is definitely out there.