What to expect from alternative treatments Acupuncture. While acupuncture does appear to reduce the frequency of hot flashes in the short term, such benefits have not been sustained.35,36 What’s more, clinical studies have found sham acupuncture and true acupuncture to be beneficial, so the placebo effect may be an important factor in the success of this modality.35
Herbal remedies. A number of herbal preparations have been touted to improve hot flash frequency and severity: Black cohosh, red clover, St. John's wort , and omega-3 fatty acids have shown some benefit, although more research is needed to determine optimal dosing and ensure safety of use.5,21,37-39 Magnesium (400 mg/d), with its minimal adverse effects and low cost, has also recently emerged as an attractive option for hot flash control.40 No randomized double-blind clinical trials have been done, however, to test the effectiveness of these preparations.
Kava kava, vitamin E, evening primrose oil, and dong quai should be avoided. All have shown little or no benefit and have potentially serious adverse effects.5
FAST TRACK
Because of limited systemic absorption and lower doses, local estrogen can be used by virtually all women with atrophic vaginitis associated with menopause.
Question patients about other menopausal symptoms
Treating hot flashes alone is not enough. It is important to address the full spectrum of menopausal symptoms, including insomnia, atrophic vaginitis, impaired sexual function, and hair loss.
Is she getting a good night’s sleep? Insomnia—a common complaint of menopausal women—may be unrelated to, or a consequence of, hot flashes. Sedating hypnotics, and at least one herbal remedy, may help with both.
Eszopiclone (3 mg, taken at bedtime) has been shown to alleviate insomnia-related hot flashes. With sufficient sedation, night sweats and hot flashes go unnoticed, and both sleep and mood typically improve.41 Other sedating hypnotics have not been studied in this patient population, but would likely have similar effects.
Magnolia bark supplements may be a preferred sleep aid for women who hesitate to take a sedating hypnotic medication. This herbal remedy has been found to decrease anxiety, irritability, and insomnia related to menopause,42 although there is limited research regarding long-term benefits and adverse effects.
Is she experiencing vaginal dryness?
For about 50% of menopausal women, symptoms associated with atrophic vaginitis impair sexual function and quality of life.43 Clinical signs such as thinning of the vaginal epithelium and loss of rugae can be seen 2 to 3 years after the onset of menopause, but many women do not report symptoms until 4 to 5 years postmenopause.43 Sexually active women tend to have fewer menopausal symptoms in general, and less atrophic vaginitis in particular.44
Common symptoms include vaginal dryness (affecting 75% of menopausal women); dyspareunia (38%); and itching, unusual vaginal discharge, and pain (15%).43 Urinary tract infections secondary to atrophic vaginitis are common, as well. Yet only 25% of women with atrophic symptoms report them to their physicians—and nearly 70% say that their health care provider has never asked about them.43 Failure to diagnose and treat atrophic vaginitis leads to unnecessary suffering, as many effective treatments exist (TABLE 3).43,45-49
Topical estrogen is the most effective treatment for atrophic symptoms. Up to 25% of women on HRT continue to suffer from vaginal dryness and may benefit from topical estrogen. Research suggests that only regimens containing estriol alleviate vaginal symptoms.43
Conversely, while women using HRT for vasomotor symptoms may find that their vaginal dryness improves, HRT should not be considered for atrophic vaginitis alone in view of safety concerns and limited efficacy.43
FAST TRACK
Magnolia bark has been found to decrease anxiety, irritability, and insomnia related to menopause, but little is known about long-term benefits or adverse effects.
Available as conjugated equine estrogens and estriol, estrone, or estradiol, topical estrogen may be delivered via cream, tablet, ring, or pessary. Adverse effects include itching, pain, vaginal discharge, and vaginal bleeding,43 but a switch to a different preparation may reduce or eliminate these problems. Endometrial proliferation has not been found to occur within 24 months of continuous use, so concomitant progesterone use is not recommended.45
Up to 90% of patients using local estrogen show improvement in atrophic symptoms within 3 weeks.43 Alternative diagnoses, such as vaginal candidiasis, contact irritation, or other vaginosis, should be considered if the condition fails to improve. Systemic absorption of estrogen—which is minimal to begin with—declines with use, as the thinness of the vaginal epithelial layer resolves. Doses can be reduced over time as less estrogen is needed to maintain healthy epithelium. The lowest effective dose should always be chosen for a patient.43
