Non-hormonal treatments for menopausal symptoms

Increasing numbers of women are requesting non-hormonal treatments for menopausal symptoms. Estrogen-containing HRT is the most effective treatment for menopausal symptoms in healthy women but is contraindicated for some women and avoided by many others. This review will assess the evidence regarding the safety and efficacy of non-hormonal treatments for menopausal symptoms. Relatively few high quality studies have addressed this issue, almost all have only addressed the treatment of hot flushes and there are few long-term data.     

Hormonal and psychological treatment: therapeutic alternative for menopausal women?

The purpose of this study was to determine whether psychological support associated with hormone replacement therapy (HRT) was more beneficial than replacement therapy alone. Our findings showed that HRT alone was more effective against vasomotor symptoms than HRT with psychological treatment (PT). While the combination of both treatment modalities (HRT+PT) was more effective against insomnia, nervousness, melancholy, fatigue, palpitations, and vertigo. Hormonal treatment alone and HRT with psychological treatment had little effect against paresthesia or tingling. Neither HRT alone nor HRT with psychological treatment was effective against joint and muscle pain or headache.     

Phytoestrogens for menopausal symptoms: a review

Objective

To review the evidence that isoflavones are effective treatments for menopausal symptoms and to present the safety data.

Methods

The databases Scopus, ScienceDirect and Primo Central Index were searched and preference was given to systematic reviews and meta-analyses.

Results

The available evidence suggests that isoflavones do not relieve menopausal vasomotor symptoms any better than placebo. Long-term safety studies suggest that women who consume a diet high in isoflavones may have a lower risk of endometrial and ovarian cancer.

Conclusions

Isoflavones cannot be recommended for the relief of hot flushes.     

Telephone-guided Self-Help Cognitive Behavioural Therapy for menopausal symptoms

Objectives

Group and Self-Help forms of Cognitive Behavioural Therapy (CBT) are effective treatment options for women with problematic menopausal hot flushes and night sweats (HF/NS). However, some women are unable to attend face-to-face sessions. This study investigates whether Self-Help CBT for HF/NS is as effective when rolled out to women living at a distance with minimal telephone guidance.

Study design

Forty-seven women completed a Self-Help CBT intervention (booklet and relaxation/paced breathing CD) during a 4-week period. They also received one ‘guiding’ telephone call from a clinical psychologist two weeks into treatment to provide support and discuss individual treatment goals. Questionnaires were collected at baseline, 6 weeks (post-treatment) and 3 months (follow-up) after the end of the intervention.

Main outcome measures

HF/NS problem rating. Secondary outcome measures: HF/NS frequency, HF/NS beliefs and behaviours, sleep, anxiety and depressed mood.

Results

There was a significant reduction in HF/NS problem-rating following the intervention which was maintained at follow-up. Moreover, women reported less frequent HF/NS along with further improvements in sleep quality, mood and HF/NS beliefs and behaviours.

Conclusions

Telephone-guided Self-Help interventions might provide an effective way of widening access to CBT treatment for HF/NS.     

Mind-body therapies for menopausal symptoms: A systematic review

Objective

To systematically review the peer-reviewed literature regarding the effects of self-administered mind-body therapies on menopausal symptoms.

Methods

To identify qualifying studies, we searched 10 scientific databases and scanned bibliographies of relevant review papers and all identified articles. The methodological quality of all studies was assessed systematically using predefined criteria.

Results

Twenty-one papers representing 18 clinical trials from 6 countries met our inclusion criteria, including 12 randomized controlled trials (N = 719), 1 non-randomized controlled trial (N = 58), and 5 uncontrolled trials (N = 105). Interventions included yoga and/or meditation-based programs, tai chi, and other relaxation practices, including muscle relaxation and breath-based techniques, relaxation response training, and low-frequency sound-wave therapy. Eight of the nine studies of yoga, tai chi, and meditation-based programs reported improvement in overall menopausal and vasomotor symptoms; six of seven trials indicated improvement in mood and sleep with yoga-based programs, and four studies reported reduced musculoskeletal pain. Results from the remaining nine trials suggest that breath-based and other relaxation therapies also show promise for alleviating vasomotor and other menopausal symptoms, although intergroup findings were mixed. Most studies reviewed suffered methodological or other limitations, complicating interpretation of findings.

Conclusions

Collectively, findings of these studies suggest that yoga-based and certain other mind-body therapies may be beneficial for alleviating specific menopausal symptoms. However, the limitations characterizing most studies hinder interpretation of findings and preclude firm conclusions regarding efficacy. Additional large, methodologically sound trials are needed to determine the effects of specific mind-body therapies on menopausal symptoms, examine long-term outcomes, and investigate underlying mechanisms.     

Healthcare seeking and treatment for menopausal symptoms in the United States

OBJECTIVES: A population-based study was used to describe healthcare seeking behavior for menopausal symptoms and treatment among women 40-65 years old in the United States. METHODS: Participants were recruited into the Menopause Epidemiology Study from the KnowledgePanel(SM), which is selected by random digit dialing and probability sampling from the US population. From this source, 6201 women 40-65 years old were contacted and 4402 women participated. From the 3135 peri- and postmenopausal women, detailed information was obtained on menopausal symptoms, healthcare seeking, medication usage, and symptom relief from the medication. RESULTS: Many women (60%) reported seeking health care for their menopausal symptoms. More than half of these women sought health care in the past 12 months. Vasomotor symptoms were the most frequently reported menopause symptoms across all races/ethnicities, and the most common symptoms discussed with a health care professional. One-third of the women (34%) used only hormone therapies, 12% used complementary and/or alternative medicines, and 16% used both for treatment of menopausal symptoms. CONCLUSIONS: This study has shown that a large number of women consult healthcare providers for menopausal symptoms, indicating these symptoms are bothersome. Yet, in the United States, there is considerable variation in the symptomatology, healthcare seeking, and use of therapies for menopausal symptoms across cultures. To alleviate these symptoms women have tried alternative treatments as well as hormone therapies, yet many women did not get complete relief of specific symptoms.     

Depressive symptoms and menopausal burden in the midlife

Objective

The goal of this study was to assess whether menopausal symptoms were more common and/or more severe among women with depressive symptoms.

Methods

A cross-sectional survey of 1358 women, ages 45–70, at two large integrated health plans (Seattle; Boston) was performed. Information on demographics, medical and reproductive history, medication use, menopausal experience and depressive symptoms (PHQ-8) were collected. Women taking HT were excluded. Logistic regression models adjusted for age and body mass index tested the associations between menopausal symptoms (hot flushes, night sweats, vaginal dryness and dyspareunia) and presence of moderate/severe depressive symptoms.

Results

770 women were included; 98 (12.7%) had moderate/severe depressive symptoms and 672 (87.3%) had no/mild depressive symptoms. Women with moderate/severe depressive symptoms were almost twice as likely to report recent vasomotor symptoms (hot flashes and or night sweats) vs. women with no/mild depressive symptoms (adjusted odds ratio (aOR) 1.67, 95%CI 1.04–2.68), and to report them as severe (aOR 1.63, 95%CI 0.95–2.83). A higher symptom burden was observed despite the fact that 20% of women with moderate/severe depressive symptoms (vs. 4.6% no/mild depressive symptoms) were using an SSRI or SNRI, medications known to improve vasomotor symptoms. The percentage of women with menopausal symptoms, and the percentage with severe vasomotor symptoms were linearly associated with the depressive symptom score.

Conclusions

Depressive symptoms “amplified” the menopausal experience, or alternatively, severe vasomotor symptoms worsened depressive symptoms.     

Relations among menopausal symptoms,sleep disturbance and depressive symptoms in midlife

Objectives

To investigate the relations among hot flashes, other menopausal symptoms, sleep quality and depressive symptoms in midlife women.

Methods

A large population-based cross-sectional study of 639 women (ages 45–54 years) consisting of a questionnaire including the Center for Epidemiologic Studies-Depression (CES-D) Scale, demographics, health behaviors, menstrual history, and menopausal symptoms.

Results

After controlling for menopausal status, physical activity level, smoking status and current self-reported health status elevated CES-D score is associated with frequent nocturnal hot flashes, frequent trouble sleeping, experiencing hot flashes, nausea, headaches, weakness, visual problems, vaginal discharge, irritability, muscle stiffness, and incontinence.

Conclusions

The present study found significant links between depressive symptoms and several menopausal symptoms including hot flashes, sleep disturbance, irritability, muscle stiffness, and incontinence after controlling for covariates. These findings suggest that a potential mechanism in which bothersome menopausal symptoms may influence depressed mood during the midlife is through sleep disturbance.     

Depressive symptoms, menopausal status, and climacteric symptoms in women at midlife

OBJECTIVE: Previous studies have found increased rates of depression in women aged 45 to 54 years, but the factors that influence these rates are not understood. It was assessed whether higher rates of depressive symptoms were associated with menopausal status, climacteric symptoms, and use of hormone replacement therapy. DESIGN: Cross-sectional survey. SETTING: Community sample. METHODS: Data are from 581 women ages 45 to 54 years who were interviewed by telephone between October 1998 and February 1999. MEASURES: Depression was measured with the abbreviated CES-D, a depressive symptoms screening measure. Women's reported perception of menopausal stage, frequency of periods in the preceding 12 months, and history of oophorectomy were used to classify their menopausal status into four categories: (1) no indication of menopause; (2) close to menopause; (3) had begun menopause; and (4) had completed menopause. RESULTS: There were 168 women (28.9%) who reported a high level (> or = 10) of depressive symptoms when the abbreviated CES-D was used. In a logistic-regression analysis, significant factors associated with increased depressive symptoms included physical inactivity, inadequate income, use of estrogen/progesterone combination, and presence of climacteric symptoms (trouble sleeping, mood swings, or memory problems). Menopausal status was not associated with depressive symptoms. CONCLUSIONS: In this sample of women age 45 to 54 years, climacteric symptoms but not menopausal status were associated with higher rates of depressive symptoms.     

Estrogenic activity of herbs commonly used as remedies for menopausal symptoms

OBJECTIVE: Women are increasingly turning to herbal therapies in an effort to manage their menopausal symptoms. In this study, we investigate the estrogenic activity of four selected herbs commonly used in menopause, namely dong quai, ginseng, black cohosh, and licorice root. DESIGN: We investigated the effect of these selected herbs on cell proliferation of MCF-7 cells, a human breast cancer cell line. We also assessed their estrogenic activity in a transient gene expression assay system using HeLa cells co-transfected with an estrogen-dependent reporter plasmid in the presence of human estrogen receptor ER alpha or ER beta cDNA. Finally, we investigated the estrogenic activity of these herbs using a bioassay in mice. RESULTS: Dong quai and ginseng both significantly induced the growth of MCF-7 cells by 16- and 27-fold, respectively, over that of untreated control cells, while black cohosh and licorice root did not. The herbs tested failed to show transactivation of either hER alpha or hER beta and had no effect on uterine weight in vivo when administered orally to mice for a period of 4 days. CONCLUSIONS: Our studies show that dong quai and ginseng stimulate the growth of MCF-7 cells independent of estrogenic activity. Because of the lack of efficacy and the potential for adverse effects, use of these herbs in humans warrants caution pending further study.     

A pilot study of a Hatha yoga treatment for menopausal symptoms

OBJECTIVE: To assess the feasibility and efficacy of a yoga treatment for menopausal symptoms. Both physiologic and self-reported measures of hot flashes were included. METHODS: A prospective within-group pilot study was conducted. Participants were 12 peri- and post-menopausal women experiencing at least 4 menopausal hot flashes per day, at least 4 days per week. Assessments were administered before and after completion of a 10-week yoga program. Pre- and post-treatment measures included: Severity of questionnaire-rated menopausal symptoms (Wiklund Symptom Check List), frequency, duration, and severity of hot flashes (24-h ambulatory skin-conductance monitoring; hot-flash diary), interference of hot flashes with daily life (Hot Flash Related Daily Interference Scale), and subjective sleep quality (Pittsburgh Sleep Quality Index). Yoga classes included breathing techniques, postures, and relaxation poses designed specifically for menopausal symptoms. Participants were asked to practice at home 15 min each day in addition to weekly classes. RESULTS: Eleven women completed the study and attended a mean of 7.45 (S.D. 1.63) classes. Significant pre- to post-treatment improvements were found for severity of questionnaire-rated total menopausal symptoms, hot-flash daily interference; and sleep efficiency, disturbances, and quality. Neither 24-h monitoring nor accompanying diaries yielded significant changes in hot flashes. CONCLUSIONS: The yoga treatment and study procedures were feasible for midlife women. Improvement in symptom perceptions and well being warrant further study of yoga for menopausal symptoms, with a larger number of women and including a control group.     

Management of menopausal symptoms in breast cancer patients

In breast cancer patients, menopausal symptoms such as hot flashes, urogenital problems, musculoskeletal symptoms and cognitive dysfunction are common, regardless of age at diagnosis. They affect quality of life and systemic therapy will worsen this. Endocrine and/or chemotherapy may induce temporary or permanent ovarian failure and can exacerbate these symptoms. Hormone therapy (HT) has been studied in breast cancer survivors, but safety has been questioned. The HABITS trial investigating estrogen-based HT, as well as the LIBERATE trial investigating tibolone, found a reduction in disease-free survival for those treated. Alternative strategies are needed, as menopause symptoms may reduce compliance with breast cancer treatments. This article reviews recently published strategies to tackle menopausal problems in breast cancer patients. Antidepressants may help with hot flashes. Acupuncture and hypnosis can also be used but the evidence is conflicting. For urogenital problems vaginal moisturizers or topical estrogens can be employed. A musculoskeletal syndrome induced by aromatase inhibitors (AIs) is frequently encountered and currently there are no effective treatment strategies. Bisphosphonates reduce AI-induced bone resorption and can also increase disease-free and overall survival. Standard-dose endocrine and chemotherapy are associated with a decline in cognitive function.     

Hormonal and psycho-relational aspects of sexual function during menopausal transition and at early menopause

Objective

The aim of the present observational, cross-sectional study was to examine the effects of hormonal and psycho-relational variables on sexual function during menopausal transition and at early postmenopause in women with hot flushes.

Study design

The sample comprised 138 women referred to a clinic for the treatment of hot flushes. They were categorised according to their stage of menopausal transition using the STRAW criteria: early menopausal transition (EMT) if their menstrual cycle was 7 or more days different from normal; late perimenopause (LMT) if they had experienced 60 days or more of amenorrhoea; and early postmenopause (EPM) if their amenorrhoea had lasted for at least 12 months but less than 4 years.

Main outcome measures

Sexual function was measured by using the Female Sexual Function Index (FSFI), while anxiety (state and trait), depression, eating disorder and marital adjustment were evaluated by validated self-report questionnaires. Levels of free testosterone (FT), dehydroepiandrosterone sulfate (DHEAS) and estradiol (E2) were also measured.

Results

Overall sexual function varied significantly with stage of menopause, with total FSFI score less in EPM than in EMT (p = .009). A similar pattern was evident on FSFI sub-scales for sexual desire (p = .02), arousal (p = .01) orgasm (p = .01) and also pain (p = .02), but not for lubrication and satisfaction. Ratings for anxiety, depression and eating disorder did not differ across the menopausal sub-groups, and neither did ratings of marital adjustment. Both FT (p = .01) and DHEAS (p = .03) levels were slightly reduced at EPM in comparison with EMT, as were E2 levels (p = .001 EMT versus LMT; p = .0001 LMT versus EPM). In multiple regression analyses, plasma FT level was the only factor to predict FSFI full score (β = .48; p = 0.004) in women at EMT, while in women at LMT the depression score was the only factor to do so (β = −.62; p = 0.0001). The best model predicting FSFI full score at EPM included levels of DHEAS and E2 levels and state anxiety score.

Conclusions

Hormonal and some psychological variables are relevant to sexual function in symptomatic women during menopausal transition and at early menopause but their role differs with the specific stage of reproductive ageing.