The results of recent large clinical trials have led physicians and patients to question the safety of menopausal hormone therapy. In the past, physicians prescribed hormone therapy in an attempt to improve overall health and prevent cardiac disease. Hormone therapy appears to increase the risk of breast cancer when used for more than three to five years. For this reason regulatory agencies now advise that physicians prescribe it only to treat menopausal symptoms such as hot flashes and vaginal atrophy with the smallest effective dosage and for the shortest possible duration. Although estrogen is the most effective treatment for hot flashes, alternatives such as venlafaxine and gabapentin are effective for some patients. Herbal formulations such as dong quai, ginseng, kava, and dietary soy do not appear to benefit patients more than the placebo. In contrast to systemic estrogen therapy, topical estrogen therapy for vulvovaginal atrophy is more appealing for certain patients because it does not require the addition of a progestogen for endometrial protection. Some have advocated selective estrogen reuptake modulators as alternatives to hormone therapy for the prevention of menopausal osteoporosis. The decision to use either therapy depends on clinical presentation and a thorough evaluation of the risks and benefits. Both therapies have potential detrimental health effects and are linked to an increased risk of venous thromboembolism.
Menopause is a normal, physiological transition when a woman stops producing eggs and ovarian function diminishes. Menopause can cause bothersome symptoms such as hot flashes or vaginal dryness. The media attention to recent clinical trials of treatments for menopausal symptoms has provided women with a large amount of information, and some of it is contradictory. This makes it challenging for patients to understand which treatment options are available, effective, and safe. In the past, physicians typically prescribed hormone therapy for menopause. Now they increasingly prescribe medications to treat specific symptoms. The U.S. Food and Drug Administration (FDA) issued a boxed warning for hormone preparations and with the American College of Obstetricians and Gynecologists (ACOG), advised that hormone therapy be prescribed at the lowest effective dosages and for the shortest possible duration.1,2 Dozens of medications dominated by hormone formulations are available to treat menopausal symptoms. When counseling menopausal patients, physicians should understand the benefits and risks of hormone therapy and alternative treatments, and should know the key differences among the various delivery systems.
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