Menopause is not a disease or a disorder. The transition to menopause is a point in time 12 months after a person’s last period. After this transition, many feel they no longer need to worry about painful periods and uncomfortable cramps, and they no longer can become pregnant. Menopause impacts everyone differently. There are many factors to consider when thinking about how you and your health care provider treat the symptoms of menopause.
Transitioning to menopause most often begins between the ages of 45 and 55. Menopause occurs when the ovaries, which have ovulated monthly since puberty, run out of eggs. The ovaries create three primary hormones: estradiol, progesterone and testosterone, which run the menstrual cycle and have many effects throughout the body. Menopause creates a deficiency in all three sex hormones, with immediate and long-term effects.
The short-term symptoms are well known, including hot flashes, disrupted sleep (from hot flashes), altered mood and concentration (due to disrupted sleep), vulvar and vaginal dryness, and the loss of libido and sexual pleasure.
One approach to treatment is restoring the missing hormones with hormone replacement therapy, HRT. HRT became prevalent in the 1970s. In the last 30 years, there has been controversy as to the value, safety and public health benefits of estrogen therapy. Long-term studies show that HRT can be safely given without increasing overall risk of disease. This is a nuanced therapy, however. Current evidence shows that HRT has overall health benefits, if started within the decade after menopause that the risk of complications from taking HRT for 5 to ten years is very low. If started after that, when atherosclerosis (hardening of the arteries) and other diseases have begun, the benefits are less and harms are more evident.
Some cannot use estrogens safely and must have alternate treatments. These include people with histories of hormone-sensitive breast cancer, spontaneous clots in their veins (venous thrombosis), or active liver disease.
Fortunately, there are alternatives to HRT. Non-hormonal therapies for each of the symptoms of menopause are readily available.
For hot flashes, lifestyle changes such as wearing less nightclothes, sleeping on a regular schedule, getting regular exercise, and taking certain supplements can be helpful. Also, eat a balanced diet and avoid stimulants, such as caffeine.
If these approaches don’t work, several non-hormonal therapies can block hot flashes, including the anti-depressants venlafaxine, fluoxetine and paroxetine. Only paroxetine is FDA approved for this purpose. My experience is that venlafaxine works best and at very low doses; a dose of 37.5 mg will block flashes, while depression usually requires 150-225 mg. Two anti-hypertensives, methyldopa and clonidine, are also effective.
I will often suggest to the patient’s internist that someone diagnosed with hypertension (high blood pressure) who experiences bad hot flashes be switched to one of these drugs in order to get the hot-flash blocking effect. Gabapentin, an anti-epileptic medication, also blocks flashes. It also has the potential for other side effects including drowsiness and can cause some people to become dependent on the medication. People who use it for other reasons often find their flashes improve.
Those who use thyroid medication, Ritalin or Adderall, and who are having flashes should have their doses kept low. As with any change in medication, speak with your health care provider to understand all of the benefits and risks.
To treat dryness, lubricants, application of topical oils, pelvic floor exercises and regular intercourse help to maintain skin and muscle tone, improve sexual comfort and increase vaginal moisture but do not reverse atrophy.
Oils are mostly useful for those with mild symptoms. Oils are applied lightly at the introitus (the opening of the vagina) and gently rubbed into the skin. I advise patients to do this twice a day. Virgin olive oil, coconut butter or oil and almond oil are all effective.
Commercial vaginal moisturizers are widely available in pharmacies and online and should be used two or three days per week, not just during sexual activity. Lubricants are used only during sexual activity and work best when applied to both partners.
While estrogens are the most effective medical therapy, hormonal medications other than estrogen are also available for genitourinary syndrome of menopause, a variety of symptoms that affect the genital and urinary systems.
Laser phototherapy promotes healthy skin
Since 2014, gynecologists have used fractional CO2 laser phototherapy to treat vulvo-vaginal dryness.
Phototherapy exposes the vaginal and vulvar skin to a specific wavelength of light, which stimulates the growth of healthy skin and connective tissue. Despite the word “laser,” this is not a beam and it does not cut or burn.
Phototherapy is administered by a probe that delivers the light in a diffuse grid to the entire vaginal vault. Growth of healthy skin and connective tissue are imperceptible to the patient but begin within two weeks of therapy. Three treatments are given at monthly intervals. My experience with phototherapy is that virtually all patients regain normal vaginal health within three months, including the ability to have comfortable intercourse and in many cases, correction of urinary incontinence.
The effects of phototherapy last for two or more years. Phototherapy effectively treats vulvovaginal dryness and discomfort, tissue fragility and painful sex (dyspareunia). There are no known risks of phototherapy.
As you or someone you love approaches the onset of the menopausal transition, it’s important to remember that the outlook for those at this stage of life is generally positive. We can safely treat most people with thoughtful use of estrogens. For those who decline, cannot take or are unable to benefit from such therapy, there are good alternatives for virtually all of the symptoms. Have a conversation with your health care provider to learn more about your options.
Robert S. Howe, MD, FACOG, is the director of Reproductive Endocrinology and the physician director of OB/GYN ultrasound at Cooley Dickinson Medical Group Women’s Health.