As described in the last three posts, perimenopause is a time in a woman’s life associated with many symptoms and health impacts. Thus far I have reviewed lifestyle modifications and hormone treatments that are helpful during this transition. This post addresses other medical interventions that may be considered – particularly for women who find that lifestyle changes have not been effective and who are unable or unwilling to take hormone replacement.
Hot Flash Options
The majority of women going through perimenopause experience hot flashes and/or night sweats. Estrogen is clearly the most effective remedy for hot flashes, but there are a variety of over-the-counter products as well as several prescription medications that may offer women some relief.
Non-prescription options for hot flashes
The Menopause Society, in its recent position statement, reviewed the studies that analyzed the effectiveness and safety of non-prescription supplements. The results are summarized in the table below. Overall, because of conflicting, inconsistent, or limited evidence, the panel did not rate any of them as highly beneficial. However, some women will find that a particular product will work for them. It is important to realize that OTC products are not regulated for safety to the extent that FDA-approved drugs are. Purchasing a product from a reputable source is advisable.
| OTC supplements with studies showing some benefit | OTC supplements where studies have not shown significant benefit |
| Soy extracts | Black cohosh |
| Equol | Don quai |
| Pollen extract (Relizen, Serelys, Femal, Femalen) | Evening primrose |
| Ammonium extract (Amberen) | Wild yam extracts |
| Rhubarb extracts | Chasteberry |
| Milk Thistle | |
| Vitamin E | |
| Omega 3 fatty acids | |
| Cannabinoids |
Prescription options for hot flashes
A new FDA-approved drug for hot flashes is Veozah. This works by suppressing the chemicals in the brain that trigger the hot flash. Studies show that it is almost as effective as estrogen. It is important to realize that drugs in this class have not been extensively studied over the long term. The FDA recently required that the manufacturers post a warning of possible liver toxicity with these drugs and recommended that women have liver function tests taken after they begin the drug.
The only other drug approved by the FDA to treat hot flashes is paroxetine (Paxil). This drug belongs to the class of drugs called selective serotonin receptor inhibitors (SSRIs) which are generally used to treat anxiety and depression. There are a number of drugs in this class including Prozac, Zoloft and Celexa. These have also been used “off-label” and probably are generally as effective as Paxil, but studies have not been done to confirm this. As a class, these drugs are not as effective as estrogen for hot flashes and can cause side effects such as stomach upset, weight gain, and decreased sexual drive.
Over the years a variety of other drugs approved for other conditions have been used for hot flashes with variable success. These include gabapentin and Lyrica (drugs used to treat several neurological disorders), clonidine (a blood pressure lowering drug) and oxybutynin (a drug for overactive bladder). None of these drugs are as helpful as estrogen, and they all have a moderate chance of fairly bothersome side effects.
Sleep option treatments
Since hot flashes contribute to the sleep problems that many women experience, any of the drugs listed above may be helpful for sleep. There are a number of other sleeping pills on the market, but those that can cause addiction are to be avoided for chronic use. Non-addictive drugs such as Benadryl and other sedating agents such as some types of antidepressants have been helpful as sleep aids for some women.
Mood swings and brain fog
The antidepressant medications noted above that have been shown to help hot flashes also help combat depression and anxiety. Thus these are frequently prescribed with the hope of relieving multiple symptoms with one drug. Over-the-counter medications such as antihistamines may help anxiety symptoms. A number of supplements and herbal medicine are reported to help combat mood issues. But, as noted previously OTC products are not rigorously controlled for purity and safety so there is always a concern about using them.
There is no magic pharmacologic bullet that can help the cognitive changes that women experience during perimenopause. However, treatments that help anxiety, depression, and sleep will improve a woman’s ability to function mentally and process information.
Vaginal symptoms and uterine bleeding
OTC vaginal moisturizers such as Replens and KY products can be helpful for vaginal dryness. It is recommended that women choose products that are low in osmolality and devoid of fragrances and other non-essential ingredients.
There are also many vaginal lubricants on the market. These should be used to help decrease discomfort with intercourse. Products that are water based or silicone based are recommended.
Irregular bleeding is common in perimenopause and there are no non-hormone treatments to regulate the menstrual period. Once any worrisome pathology is ruled out, some women are treated with drugs such as tranexamic acid or non-steroidal anti-inflammatory drugs to help control bleeding. If women are found to be iron deficient, taking iron supplements can also help.
Bone health
As noted, bone loss occurs rapidly during perimenopause. Getting adequate calcium, vitamin D and exercise are critical, but aren’t enough on their own to prevent the significant loss that occurs during this transition.
Women at high risk for osteoporosis should be evaluated and may be candidates for some of the non-hormonal bone preserving drugs such as Evista, Fosamax, or Prolia. However, these drugs are not approved merely as a preventative measure for women with normal bone densities who enter perimenopause.
Heart health, diabetes and belly fat
During perimenopause the blood pressure, cholesterol and blood sugar tend to rise. It is important to have these values checked. If lifestyle measures such as diet and exercise don’t control elevated values, there are abundant medical options for treatment. Weight loss drugs are available for patients with obesity or weight-related medical disorders.
In summary
Every woman goes through the menopause transition in her unique way. There are many non-hormonal products that can address various aspects of the symptoms and medical issues that arise during perimenopause. As is the case with hormonal-based treatments, each woman should be managed according to her individual health situation and preferences. There is no “one size fits all” treatment for perimenopause!
As always, thank you for keeping up with and sharing the research to help us make informed decisions about our health, Dr. Rice.
I enjoy reading your posts and sharing with friends.
Thank you again Catherine!