Posts Tagged ‘paroxetine’

Black Cohosh
One of the most popular herbal supplements used to alleviate hot flashes is black cohosh. This plant is native to North America and was used by Native Americans for a range of medicinal purposes. The botanical name has been changed in recent years, so some references refer to this plant as Cimicifuga racemosa whereas others use the current term, Actaea racemosa. The famous 19th-century patent medicine promoted for “women’s problems,” Lydia E. Pinkham’s Vegetable Compound, contained black cohosh as a prominent ingredient.
A standardized extract of black cohosh called Remifemin has been studied in Europe and found to effectively reduce Remifemin
This standardized extract of black cohosh is consistent and widely available. The recommended dose is 40 to 80 milligrams per day.
Side effects: Digestive upset
Downside: Not to be taken during pregnancy; monitor for liver toxicity
Cost: Approximately $15 to $30 per month
hot flashes.739 Physicians who scoff at herbal remedies appreciate that this research was published in a highly respected peer-reviewed journal, Obstetrics and Gynecology (May 2005). In one trial, Remifemin was compared to a low-dose transdermal estrogen preparation.”O The treatments were equally effective in reducing hot flashes, and neither one was associated with serious side effeCtS.141
Most reviews suggest that the side effects of black cohosh are infrequent and generally mild—mostly digestive upset with some headache or dizziness reported. 42 Just the same, we think that women should discuss this supplement with their doctor. Although recent studies of black cohosh have monitored liver enzymes and found no changes, there are reports of liver toxicity among women taking black cohosh.741 Women who have had hepatitis or other liver problems might want to consider a different approach. For most healthy women, 6 months or so of black cohosh may be worth trying, and it seems fairly safe.744 Unfortunately, black cohosh does not relieve hot flashes that result from breast cancer treatment with tamoxifen.
The Soy Solution
One of the other popular approaches to managing hot flashes is soy. Isoflavones such as genistein and daidzein are phytoestrogens, estrogen-like compounds derived from plants. Even though they are far weaker than the estrogen a woman’s own ovaries make before menopause, it seems logical to use these compounds to ease hot flashes. Studies from cultures like Japan, where women consume soy products such as tofu and ** Soy
The results of studies on soy have been inconsistent. Soy may be consumed as shakes, bars, or more traditional soy foods such as tofu or tempeh. Women who have more hot flashes may derive more benefit.
Side effects: Unpalatable taste, digestive distress Downside: Not advised for women being treated for breast cancer; excess soy may interfere with the production of thyroid hormone
Cost: Approximately $15 to $50 per month
tempeh as part of their normal diet, suggest that hot flashes and other menopausal symptoms may be less common there. 745
Despite the epidemiological promise, research on soy against hot flashes has been disappointing overall.746.747 One review of many trials, however, found that women who began the studies with frequent hot flashes got more relief from soy foods or isoflavone supplementation than did women who rarely had hot flashes.’ 48 A different systematic review delivered a lessthan-ringing endorsement of the effectiveness of soy preparations against hot flashes, but the authors did conclude that the risks appear to be low. 74″ As the authors of one pilot study concluded, a soy extract (they were testing Phytosoya) appears to reduce hot flashes and night sweats and is probably worth a try if women don’t want to take standard HRT.750
Red Clover
Another source of isoflavones that is marketed for perimenopausal women is red clover (Trifolium pratense). Although this plant is native to North America, its extracts are sold by an Australian firm as Promensit and Rimostil. Most of the research on red clover isoflavones has been funded by the manufacturer Novogen. Nonetheless, the results vary. One small Dutch study found a significant effect, with Promensil reducing hot flashes by 44 percent more than placebo.”‘ But a larger, multicenter trial in the United States found no clinically significant effect on hot flashes with either Promensil or out of the study, and no side effects were significantly more common among those taking red clover extracts than among those on placebo. Analyzing the data for subgroups uncovered a trend toward heavier women getting more benefit from Promensil.153 Overall, however, red clover does not seem very impressive.
Vitamin E
-the North American Menopause Society suggests taking vitamin E along with keeping cool, exercising, not smoking, eating soy isoflavones, and taking black cohosh as inexpensive,.probably helpful nonprescription measures to alleviate hot flashes. Quite a few women have heard that vitamin E can be helpful for this symptom, and some have passed the advice along to their friends.    9
A. I’m 53 and haven’t had a period for a year. I have no problems other than hot sweats.
I recently started taking 400 IU of vitamin E each day and, much to my amazement, it really works. Is there anything I should know about this vitamin?
A. Many women tell us that vitamin E can be helpful for hot flashes. Don’t count on it to protect you against cancer, though. Smokers should probably not take vitamin E supplements, because there is some fear it may actually increase their risk of lung cancer. For others, moderate doses of vitamin E seem safe for short periods of time.
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Unfortunately, there appears to be very little research on the effectiveness of vitamin E. Some of the buzz may have come from a study done more than 50 years ago.7-14 Usually we would like to see more recent research to back up a recommendation, but little seems to have been done.— Nonetheless, the North American Menopause Society considers vitamin E, like black cohosh and isoflavones, safe enough to be worth a try.
Vitamin E has performed poorly in several recent studies of cancer prevention, and women who are at particularly high risk of lung cancer—smokers, for example—should probably avoid taking large doses of vitamin E without other antioxidant nutrients. But healthy women planning to take vitamin E for a year or two to ease hot flashes probably will not notice any unpleasant effects. The best product is a combination of natural tocopherols. As with other products, start with the lowest dose available and gradually increase it to find the lowest dose that helps with your symptoms.
It is disappointing that vitamin E has received so little scientific attention over the years. That hasn’t stopped women from trying it, though. Of course, we frequently hear about other interesting nutritional supplements that have worked for a few women but have no scientific evidence to support or refute their effectiveness. If they are otherwise safe, we see no harm in experimenting.
/ can’t help but wonder why most doctors do not treat hot flashes and night sweats with bioflavonoids. As a retired registered nurse, I have found that daily use of bioflavonoids will relieve both the hot flashes and the night sweats. It saves the worry of cancer threats from hormones and is much less expensive. I use Citrus Bioflavonoid Complex, 1,9W milligrams, providing 35 percent hesperidin, 350 milligrams. [Hesperidin is a compound found in citrus fruits that has anti-inflammatory activity.]
At one time, I was hesitant to suggest this to my daughter-in-law because she had been successfully treated for breast cancer When we were visiting and she was showing the lack of sleep front hot flashes and night sweats, I finally bought bioflavonoids for her She often thanks me for the relief that it has given.
Nonhormonal Therapies
For years, women have worried about the possibility that estrogen and progesterone could increase their risk of breast cancer. Women who have already been treated for breast cancer can’t take these hormones safely. As a result, and in light of the negative results from the WHI research, physicians have been looking for other ways to alleviate hot flashes. One approach that seems to help is an antidepressant in the selective serotonin reuptake inhibitor (SSRI) family.
PAXII.
Some doctors now prescribe antidepressants like Paxil (paroxetine) to help women deal with hot flashes. A recent study found that Paxil was significantly better than placebo in reducing the number of hot flashes and easing their intensity. 755 Low-dose Paxil (10 milligrams per day) was also better than placebo in preventing nighttime awakening, presumably due to night sweats. Women in this study did not have to be depressed to get benefit. That also seems to be the case for drugs such as Effexor (venlafaxine).71
Such medications are not without their own drawbacks, though. They can cause sweating, nausea, dry mouth, constipation, insomnia, jitteriness, and sexual problems such as difficulty achieving orgasm. Both Paxil and Effexor also can be difficult to discontinue. Stopping suddenly can lead to odd and distressing symptoms such as dizziness, sensations similar to electric shock, and a peculiar feeling that has been described as “brain sloshing” or “head in a blender.” If antidepressants are taken for hot flashes, they should be taken at the lowest dose that works for the shortest time needed, just like hor-
** Paxil (paroxetine)
Paroxetine eases hot flashes due to menopause or associated with breast cancer drugs such as tamoxifen. The effect on hot flashes is independent of its antidepressant activity. Women found a lower dose easier to tolerate.
Side effects: Nausea, digestive problems, weakness, sleep disturbances, dizziness, nervousness, sexual difficulties, hyqe.m )siio% we*ig1ht gain
Downside: Paxil can be hard to stop taking. You may need your doctor to switch you to a longer-acting drug such as Prozac and then decrease the dose gradually over several weeks or months.
Cost: Approximately $75 to $90 per month move replacement therapy. And, also like HRT, they may need to be tapered off gradually.
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Q. 1 have been having hot flashes, night sweats, mood swings, and other change-of-life problems for more than a year. I had hoped these problems would eventually go away, but so far they haven’t.
My doctor wants me to consider Premarin, but I worry about side effects, especially breast cancer. It runs in my family.
The other drug my doctor has suggested is Zoloft. But I am not depressed and don’t want to deal with side effects from that drug either. Do you have information on natural alternatives that might help me withstand hot flashes, night sweats, and interrupted sleep?
A. Black cohosh extract has been recommended for hot flashes. A double-blind study published in Obstetrics and Gynecology (May 2005) showed that the standardized product Remifemin was significantly more effective than placebo.
Another reader shared her experience with a different herb: “I have been using St. John’s wort since discontinuing hormone replacement therapy. It has relieved many symptoms, including sleeplessness, stress, and fits of temper.”
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NEURONTI N
Anoffier approach that may help some women who are suffering with hot flashes is an anticonvulsant drug called Neuron-tin (gabapentin). Pilot studies show that 900 milligrams daily of Neurontin reduces both the frequency and intensity of hot
flashes, and that it works better than placebo.757 Because Neurontin, like the SSRI antidepressants, does not have any estrogenic activity, it may be especially helpful for women who have had breast cancer and must avoid HRT. This medicine * Neurontin (gabapentin)
Gabapentin eases hot flashes due to menopause or associated with breast cancer drugs such as tamoxifen. The effect on hot flashes is not related to its anticonvulsant effects.
Side effects: Drowsiness, dizziness, problems with balance, fatigue, swelling of the feet, nausea or vomiting, depression, reduction in white blood cells
Downside: Neurontin should not be discontinued suddenly. You should ask your doctor for help in reducing the dose gradually over several weeks or months.
Cost: Approximately $60 to $150 per month, depending on whether you get a brand-name or generic product
has been associated with some potentially serious adverse reactions, such as a reduction in white blood cells that could leave a woman susceptible to infection. We recommend having a thorough discussion of its likely benefits and risks with the prescribing doctor. This is good advice for any medication, of course, but especially for one being used for an “off-label” condition like this.
Relieving Vaginal Dryness
Hot flashes may be the most obvious symptom of menopause, but for many women, vaginal dryness is just as troublesome. And despite our culture’s greater acceptance of public discussion of sexual issues such as erectile dysfunction, for example, vaginal dryness is often too personal and too embarrassing to bring up. When the WHI highlighted the potential dangers of long-term use of oral estrogen, millions of women stopped their HRT and then searched high and tow lot a personal lubricant that would be safe and effective.
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Q. 1 know this is a sensitive issue, but it affects a lot of women. Vaginal dryness is ruining our sex lives. I had breast cancer, so hormones are out. I’m embarrassed to ask my doctor about this.
My husband works long hours, and our opportunities for intimacy are unpredictable. Is there any natural lubricant I could use just at that time?
A. Readers have suggested olive, almond, and vitamin E oils. Some people are allergic to topical vitamin E, though, and it can cause a nasty rash. In addition, using any oil in combination with latex condoms may weaken them. One woman breaks a leaf off her aloe vera plant and uses the slippery gel that oozes out.
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For some women, this problem is an issue only for sexual relations, but others find that dryness is uncomfortable throughout the day. Oral HRT generally relieves this symptom along with hot flashes, but just as sudden sweats may return when HRT is stopped, so can vaginal dryness.
Olive Oil
No studies have identified diets, exercises, or other lifestyle approaches that work for vaginal dryness. We. have heard from many women who have found remedies that work for them, however. One of the simplest is olive oil. Other women have found that almond oil has a more pleasant aroma and that it still helps with everyday moisturizing.
*** Olive Oil
If it’s safe to eat, it’s safe enough for vaginal lubrication, too. The oil is applied to the vagina with a fingertip. At first, daily application may provide the best results. Later, lessfreqxiem applications may be eileefive.
Side effects: Some women notice oily spots on their underwear. If this happens, apply less.
Downside: Some women are squeamish about fingertip application. In addition, using any oil in combination with latex condoms can weaken them.
Cost: A few dollars, or less, per month I would like to suggest a natural lubricant that is not greasy but is good for your body. It is pure olive oil. (it can be edible, too.) I have been using olive oil for this purpose for a couple of years. When my doctor did a pelvic exam, he thought I was taking hormones although I am not. I think olive oil has natural compounds to keep women youthful.
There is, unfortunately, no research to show whether any kind of oil applied topically will moisturize vaginal tissues. Our reader got a lot of other people interested in using olive oil for this purpose, though, and some of them contacted us to tell us that it helped. We really don’t know of any hazard to this one except for people who are allergic to olive oil. It doesn’t take very much, so use the best-quality extra-virgin olive oil you can find, or substitute almond oil or another vegetable oil if you
prefer.
Vitamin E
The underground popularity of vitamin E capsules taken orally for hot flashes has apparently inspired some women to try this dietary supplement “off-label.” We don’t think any vitamin manufacturer envisioned women using the contents of a vitamin E capsule for personal lubrication, but some are enthusiastic about it. They prick the capsule and squeeze out the oil for application by hand. Others use the capsule as a vaginal suppository. We caution, though, that some people are sensitive to vitamin E and might develop a rash. In addition,
** Vitamin E
Squeeze the vitamin E oil out of the capsule and apply it to either partner for lubrication “at the moment.” A capsuke may be used as avdiffinal suppository for lasting lubrication.
Side effects: Rash. Test the oil on your inner arm first, to make sure you aren’t sensitive to it.
Downside: Effectiveness has not been scientifically tested. Also, using oil in combination with latex condoms may weaken them so that they aren’t effective.
Cost: Approximately $2 to $5 per month using any oil in combination with latex condoms may weaken them.
Improbable Lubricants
Whoever said “necessity is the mother of invention” must be smiling at the ingenuity of women who have taken common, inexpensive cleansers or moisturizers and tried them to combat vaginal dryness. But some household products have been especially popular. Some years ago, we heard from a couple in their seventies who were using Corn Huskers Lotion, an old-fashioned hand lotion, as a sexual lubricant. Other readers were interested in their experience and tried the product out.
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A. 1 suffered for years from vaginal dryness and tried a lot of treatments for it. Then I read about using Corn Huskers Lotion. The results have been incredible! The lotion is inexpensive and works better than a progesterone cream my doctor prescribed. .
A. We’ve heard from others who have found that this old-fashioned hand moisturizer can be helpful for vaginal dryness. Some of the ingredients are identical to those in pricier personal lubricants.
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Corn Huskers Lotion contains glycerin, guar gum, and methylparaben, as well as a few other ingredients. It is not dissimilar to K-Y Jelly (glycerin, hyd roxymethylcel I u lose, methylparaben), Astroglide (glycerin, propylene glycol, parabens), or Replens (glycerin, mineral oil, methylparaben). All of these drugstore products are designed specifically as vaginal lubricants. Although they are a bit pricier, such products are certainly worth a try. Corn Huskers is promoted as an oil-free hand treatment lotion. The manufacturer makes no claims regarding this “off-label” use. Do keep in mind that mineral oil, as found in Replens, could compromise latex condoms.
We have also heard from many readers who sing the praises of an old-time facial cleanser for this purpose.
Q. My husband and I have used Albolene as a sexual lubricant since the early 1970s. I’m not sure how we heard about it, but it’s great: odorless, tasteless, slick, but not messy.
It comes in a white tub you can keep by the bed without embarrassment. A 12-ounce jar costs about $11, but a little goes a long way. We’ve purchased five jars in 27 years of marriage. I haven’t seen this anywhere else and wanted to share our secret.
A. Thanks for the tip. Finding a sexual lubricant that suits both partners can be challenging.
Albolene is a moisturizing cleanser that contains mineral oil, petrolatum, paraffin, ceresin, and beta-carotene. It should not be used with condoms or a diaphragm since petroleum jelly degrades latex.
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Albolene is certainly cost-effective. Although it is solid in its container, a small amount applied to the skin soon liquefies and becomes slippery. One drawback, though, is the mineral oil and petrolatum base. These petroleum products will destroy latex, so they must not be used with barrier contraceptives such as condoms or a diaphragm. (The postmenopausal woman may not need to worry about contraception, but many perimenopausal women still need to be vigilant.) Alboleneis available in pharmacies and online: for more information, you can contact the manufacturer, Numark Laboratories, at 800-338-8079.
I’ve been using a product from New Zealand named Sylk for over a year ear now and find it does a great job in lubricating and relieving pain associated with vaginal dryness during relations.
Quite a few people these days are reluctant to introduce petroleum-based products into their bodies, and they also worry about the effect of such products on latex condoms. Many of them have been pleased to learn about Sylk, a natural lubricant from New Zealand. It contains kiwifruit vine extract and, more importantly, does not contain petroleum products. As a result,  Sylk
This natural personal lubricant contains kiwifruit vine extract, citrus seed extract as a preservative, and vegetable glycerine. It is water-based, so it can be used with condoms. It is not sticky.
Side effects: None known
Downside: Effectiveness has not been scientifically tested. Cost: One bottle costs $22 to $23 and lasts 3 to 4 months.
it is safe to use with barrier contraceptives. Sylk is not available in most drugstores, but it can be ordered by telephone at 602957-7955 or on the Web at www.sylkusa.com.
People have devised a number of other clever ways to use natural products as lubricants. Some people have found that the gel from an aloe plant is ideal. It certainly is inexpensive! A few drugstore lubricants contain aloe as one of the ingredients, so presumably this is usually well tolerated.
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O. My husband and / can’t use K-Y Jelly or any other brand of lubricant we have tried. They make me itch and burn.
We have found, though, that the slimy gel that oozes from an aloe leaf when you break off a piece is a very good lubricant. I hope this will add to your uses of aloe vera and help another couple.
A. This is a most unusual sexual lubricant. Aloe vera get has been used for centuries to help burns heal and ease skin irritation.
Others who would like to try this should test the gel on the inside of the elbow first. If there is no allergic reaction, the slippery texture should make it a surprisingly effective sexual lubricant.
Hormonal Approaches
For decades, when women complained of vaginal dryness as a symptom of menopause, doctors prescribed estrogen, often as a vaginal cream. Most of the time when a vaginal cream or tablet was prescribed, the doctor would point out that it would have local effects and would not be absorbed into the bloodstream. Although vaginal estrogen creams can often help alleviate dryness, the dogma that the estrogen in the cream stays put and doesn’t get into the rest of the body is bogus. The delicate tissue of the vagina is quite efficient at absorbing estrogen and passing it into the bloodstream.758
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Q. I have been reluctant to take estrogen because I worry about possible side effects, in particular breast cancer. The worst thing about menopause has been the lack of vaginal lubrication, which makes sex very uncomfortable.
My doctor prescribed a vaginal estrogen cream for this problem. He has assured me that it is locally acting with negligible absorption.
It certainly has helped the vaginal dryness, but my hot flashes have also dropped off considerably. Is this cream getting from the vagina to the rest of my body to control the hot flashes? And if so, what about the risk of breast cancer?
A. Estrogen is easily absorbed from the vaginal lining. In fact, one study of Premarin and Estrace creams published in the Journal of the American Medical Association (December 14, 1979) found that “estrogen vaginal cream preparations, as widely used in clinical practice for their local effects on the vagina(mucosa, actually result in sus126ned high estrogen levels in the systemic circulation.”
We suggest that you discuss your risk factors for breast cancer with your physician. If oral estrogen is inappropriate for you, a cream formulation is not likely to be much safer.
There are certainly times when a vaginal cream or tablet is :appropriate. When other approaches aren’t effective, an estrogen cream often will help. As with oral estrogen, the idea is to use the lowest effective dose for the shortest possible period of time. Frequently the prescription cream will be dispensed with an applicator. Ask the doctor if you should fill the applicator or use less cream than that. It may be possible to apply just a small dab on the tip of your finger and get adequate relief with less overall exposure to estrogen. Topically applied estradiol (a form of estrogen) is available as Estrace cream and Vagifem vaginal tablets.
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Q. A couple of years ago vaginal dryness was causing me a lot of discomfort. I am prone to blood clots, so I can’t take oral estrogen.
My doctor prescribed Estring, an estradiol vaginal ring that is inserted every 3 months. It has only 2 milligrams of estrogen and has solved my problem. Please tell others about this approach.
A. Estring has been available in Sweden since 1993 and in the United States since 1996. The 2-milligram dose of estrogen is very low, especially since it is released gradually over 3 months. This approach may solve the problem of vaginal dryness with fewer side effects than oral estrogens.
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*** Estring
Estring is a vaginal silicone ring that contains estradiol that is released at a steady, low rate over 3 months, which minimizes fussing. It is placed in the vagina, usually so that it is comfortable or almost unnoticeable.
Side effects: Stomachache, nausea, vaginal discharge, headache, insomnia
Downside: Must pay for 3 months’ treatment up front Cost: $100 to $150 for a 3-month ring There is one more way to apply estrogen topically to the vaginal tissues—with a vaginal ring. This silicone ring is inserted into the vagina, where it releases estradiol at a low but steady rate for 3 months. Like other forms of estrogen, it’s not appropriate for women who have or have had breast cancer. Because the dose at any given time is lower than if a woman were taking estrogen orally, it might be used even by women who are nervous about using estrogen.
Conclusions
Although menopause is a natural process, hot flashes and night sweats can be bothersome. Vaginal dryness also may be uncomfortable. The ideal treatment for these symptoms should be used at the lowest effective dose for the shortest possible period of time, since most symptoms will eventually fade away on their own.
Here is an overview of our recommendations.
•    Keep cool by turning down the thermostat and wearing layers that can be easily removed if you start to sweat. A tall, cool (nonalcoholic) drink is less likely to trigger a hot flash than a steaming cup of coffee.
•    Keep exercising to minimize your hot flashes and help you sleep. Then follow up with relaxation and deep breathing.
O    Try Remifemin. Black cohosh can help with hot flashes if they are not too extreme.
•    Eat moderate amounts of soy products with isoflavones. They may help reduce hot flashes.
•Take vitamin E capsules. Up to 400 IU daily should be safe and might help.
•    If nothing else helps with the hot flashes, try hormone replacement therapy at the lowest effective dose for the shortest possible time. Transdermal estrogen might be worth considering.
•    An antidepressant such as Paxil (paroxetine), Effexor (venlafaxine), or Prozac (fluoxetine) may calm hot flashes even if you are not depressed. Don’t take any of these drugs for longer than you need them; you may need help getting off them.
•7be antiseizure drug Neurontin (gabapentin) may ease hot flashes and does not have the same risks as hormone re-placement therapy. Do not stop this drug suddenly, though, since that could trigger withdrawal symptoms.
•    Vaginal dryness may respond to olive oil, almond oil, or the oil from inside a vitamin E capsule.
•    Corn Huskers Lotion or Albolene offers slippery lubrication for sexual relations.
•    For more natural lubricants, try the gel from a broken aloe vera leaf or Sylk, which has kiwifruit extract. •Estring is the most convenient form of vaginal estrogen. The need for Estring should be reevaluated every 3 or 6 months so you won’t use it for longer than necessary.

MENOPAUSE
*Turn the thermostat down to reduce hot flashes
•    Use the lowest-dose estrogen and progesterone therapy for the shortest time possible
•    Try Remifemin for hot flashes    ***
•    Eat tofu or tempeh or drink soy shakes    **
•    Ask your doctor about Paxil (paroxetine) or Effexor (venlafaxine) for hot flashes
•    Inquire about Neurontin (gabapentin) for hot flashes
•    Apply olive oil topically for vaginal dryness
•    Squeeze vitamin E out of a capsule as a sexual lubricant
•    Experience slippery sex with Sylk
•    Experiment with aloe vera gel
•    Get a prescription for Estring (estradiol)    ***
Decades ago, menopause used to be referred to in whispers as The Change. The mystery surrounding the event gave it a sinister aura. Now, though, more than 5 000 women enter menopause every day in the United States. ~21 That’s because the baby-boom generation is aging. We are not a bashful bunch, and female boomers have brought menopause out in the open. Women refer to hot flashes, somewhat jokingly, as power surges. But few women relish them. Most would like some way W ease this symptom, even it it is the consequence of a perfectly natural biological process.
We ought to begin with some explanation of menopause. Most people know this refers to the time when a woman’s ovaries stop making the hormones that support the ripening and release of eggs. It is a gradual process that may be spread out over years, perhaps even a decade, and is properly referred to as perimenopause. Menopause itself is technically just one point in time: the day when an entire year has passed since the end of a woman’s last menstrual cycle.722 The average age on this day is 51 years, but women may be as young as 40 or as old as 58 and still be within the normal range for menopause.
Just as the timing of this change in ovarian function differs from one woman to another, so do the timing and intensity of menopausal symptoms (yes, we should be calling them perimenopausal symptoms). Some women barely notice a hot flash or two. We’ve even spoken with women who had “cold flashes” rather than hot flashes. Others are distressed by intense heat waves that may plague them daily for years. Most fall between those extremes but would still welcome some respite from the sweating, the flushing, and the distracting feeling that they might spontaneously combust. (Not to worry—that has never happened!)
I hope you can recommend something for my wife, who feels like she is about to burst into flames. Her doctor suggested Premarin, but she refuses to take it because she is worried about the increased risk of breast cancer What other options are there?
If it is any comfort, this period of discomfort lasts about 4 years, on average. That means, though, that some women zip through it much more quickly, whereas others take longer, sometimes much longer, to get through to relief.
The Hormone Controversy
For years, women suffering from hot flashes and other menopausal discomforts were told that their doctors had the magic solution: Just take hormones to replace the ones their ovaries were no longer making. Hormone replacement therapy, or HRT, has had its ups and downs over the decades, beginning with Premarin’s approval in 1942. Since then, more than 30 billion doses of this h101MIOnt di Wled from pregnant mares’ urine have been dispensed.
When doctors discovered that women taking Premarin were at greater risk of developing cancer of the uterine lining, this prescription went out of vogue for a while. But then researchers found that adding progestin, a synthetic form of progesterone (usually prescribed under the brand name Provers), could reduce this risk. In the 1990s, Premarin became the most prescribed pill in history. Besides easing hot flashes,night sweats, and other menopausal problems, HRT was supposed to save women’s lives by reducing their risk of heart disease, colon cancer, osteoporosis, and other serious health
threats.
These days, though, the story has changed, and a lot of menopausal women are feeling confused and betrayed. For years, they were told that they were suffering from an estrogen deficiency syndrome. Replacing the hormones their bodies no longer made was supposed to ease menopausal symptoms. Women who resisted a prescription for HRT were sometimes treated as difficult cases. Some were told that though HRT might raise the risk of breast cancer, it was a much less significant concern than heart disease, which HRT might protect against.
After I was operated on for breast cancer, I was told that I could no longer take estrogen, because my tumor was ‘estrogen-dependent’ My primary physician actually had the gall to tell me: The benefits of estrogen far outweigh the threat of breast cancer, and besides, we can cure breast cancer’
Women have a right to be furious. The hormone hype that lasted for several decades represents one of the biggest scams in modern medicine. Millions of women were guinea pigs in an uncontrolled experiment. Physicians who pride therpselves on practicing “evidence-based medicine” prescribed drugs that were unsupported by data. Many women who expressed their fears to their physicians were told in no uncertain terms that the benefits of HRT outweighed the risks.
When the National Institutes of Health announced a huge, long-term study of hormone replacement therapy, advocates of HRT were thrilled. They anticipated that the best available science would support their convictions that HRT had many health benefits, far beyond simply easing hot flashes. Thousands of women were recruited to the study and randomly assigned to take either Prempro or a look-alike placebo pill.
When the results of this study—called the Women’s Health Initiative (WHI)—were announced in 2002, many physicians were surprised and women were shocked to learn that instead of protecting women from heart disease and cardiovascular complications, HRT actually increased their risk. A few doctors had anticipated that the study might show an increased risk of breast cancer. As early as 1995, the Nurses’ Health Study, which followed more than 100,000 women, had confirmed that estrogen replacement therapy significantly increased the risk of breast cancer in postmenopausal women and demonstrated that progestin did not diminish that risk 723 If anything, the data suggested that adding progestin could increase the risk .721
Although there had been hints from previous research that estrogen, with or without progesterone, might increase a woman’s risk of breast cancer, such concerns were mostly downplayed. Opinion leaders reminded physicians that the leading cause of death in postmenopausal women is heart disease. (Breast cancer  comes in second.) Some eminent gy- necologists opined that if breast cancer was a risk, it was a minimal one, associated only with long-term HRT use. Such cancers were thought to be “good” cancers in that they were “early” cancers, easily detected and treated and not associated with increased mortality.
Further results from the WHI gave the lie to that claim. The investigators found that women taking combined HRT (Prempro) were more likely to be diagnosed with breast cancer than those on placebo and were more likely to have invasive, more advanced cancers. They concluded, “These results suggest estrogen plus progestin may stimulate breast cancer growth and hinder breast cancer diagnosis.”115
As a result of these new findings, doctors may also be feeling betrayed. They too were sold a bill of goods that did not turn out to be as advertised. It is now clear to all that HRT is not a panacea for the miseries of menopause. But what remains unclear is exactly how women should cope with hot flashes, night sweats, sleep disruption, and vaginal dryness. Finding out that estrogen doesn’t really prevent heart disease still leaves women with plenty of options for reducing their risk of heart trouble. And there are other possible treatments for osteoporosis, another condition for which women were given long-term estrogen treatment. But what can be done for those annoying, sometimes debilitating hot flashes?
Alleviating Hot Flashes
Certain simple lifestyle adjustments might be all that some women need to make hot flashes tolerable. First, turn down the thermostat. This seems too simple to work, but many menopausal women are less uncomfortable when the temperature is cooler.726 Second, dress in layers that can be easily removed. ‘Ibis is simple common sense.Third, follow the Southern belles’ example and keep a fan and a nice coot (nonalcoholic) drink handy. Fourth, keep exercising. Or if you are not already walking, swimming, or dancing, start. It’s not a miracle, but women who exercise regularly seem to have fewer hot flashes or find them less bothersome. Besides, exercise eases depression and anxiety and is beneficial for the heart and the bones as well.
Hormone Replacement Therapy
When it comes to taming hot flashes, estrogen is undeniably the gold standard. Estrogen, either alone or in combination with progestin, clearly reduces the frequency and severity of hot flashes by about 75 percent.727 This is significantly better than placebo, although women with hot flashes are susceptible to the placebo benefit.
In most studies of HRT or herbal alternatives, women taking the placebo had nearly 60 percent fewer hot flashes per week at the end of the studies, on average, than at the beginning. 721 Women on HRT, either estrogen alone or estrogen together with progesterone, also seem to have less trouble with night sweats that awaken them and disturb their sleep. There’s little evidence that herbal treatments have much effect on menopausal sleep problems, which many women find extremely disdirbing.
If it weren’t for the WHI, doctors would still be prescribing Prempro (a combination of Premarin and Provers) to virtually every menopausal woman who would take it. And they would still be encouraging women to keep taking it long after menopausal symptoms faded away, as a general-purpose “health and beauty aid.”
The characteristics of the women who were willing to use HRT before the WHI results were available probably accounted for many of the benefits seen with HRT in earlier, observational studies. Women were told that HRT was good for their health, so those who chose to take it were more likely to be the health-conscious, careful eaters, regular exercisers, nonsmokers, and occasional drinkers. Their healthy behaviors, rather than the HRT per se, are now believed to be responsible for their lower rates of heart attack, stroke, and many other problems.
The WH I put the issue of HRT and heart attack prevention to  Estrogen and Progesterone
Hormone replacement therapy reduces hot flashes significantly for most women. Women who still have a uterus need to take progesterone along with estrogen to protect themselves from endometrial cancer.
The risks of this therapy rise significantly at 5 years of use. For most women, intense hot flashes last less than 5 years. Ask for the lowest possible dose, and increase the dose only if that does not adequately relieve the hot flashes and night sweats. Hot flashes may return if HRT is stopped abruptly, so gradually tapering off it may be more successful. Transdermal estrogen (Climara, Estraderm) may be less likely to trigger nausea, but there haven’t been good headto-head comparisons.
Side effects: Breast tenderness, nausea, gallbladder problems, migraine headaches, intolerance to contact lenses, elevated blood sugar. If progesterone is given only 1 week a month, vaginal bleeding resembling a menstrual period is common.
Downside: HRT increases the risks of breast cancer and blood clots that could trigger heart attacks and strokes. These risks increase over time. HRT should be used only as long as it is needed for perimenopausal symptoms.
Cost: Approximately $40 to $75 per month for brand-name HRT; generic is available for $12 to $20 per month
the test with more than 16,000 postmenopausal women. Unfortunately, HRT did not pass. Women who had never undergone hysterectomy were randomized to Prempro or placebo, but the study was stopped early when it appeared that the women taking HRT were at greater risk than those on placebo .129 Although Prempro had been expected to protect women from heart attacks and strokes, the results showed that women taking this HRT were nearly 30 percent more likely to develop coronary heart disease and twice as likely to come down with a pulmonary embolism, a dangerous blood clot in the lung.730
None of this has much bearing, though, on the use of hormones to treat hot flashes. The risks are primarily for women who take Prempro or other forms of estrogen and progester-one for extended periods of time.The most recent recommendations, based on subanalyses of the WHI data, suggest that women just entering menopause (ages 50 to 54 in particular) may be more resistant to the dangers of estrogen and might even get some protection from heart attacks by taking it. 31 Short-term use (for a few months up to a couple of years) to get through the worst of the hot flashes doesn’t seem to pose an excessive risk for most women. Those who have previously had dangerous blood clots or breast cancer or who have a strong family history of breast cancer should probably avoid estrogen even in the short term, however.
O. 1 took hormones for 4 years and then discontinued them for a year. Now I have started again, at the urging of my doctor. While I was not taking hormones, I had hot flashes, night sweats, and vaginal dryness.
I stopped taking hormones because the progesterone component made me irritable and depressed. (I was taking Premarin and Provera.) My doctor put me on Estrace and Prometrium this time, but I still feel prickly and sad.
I’m convinced progesterone is the problem, so I wonder if I can take the estrogen alone. I recently read that estrogen has heart benefits.
A. The hormone controversy has heated up again. A study showed that women between the ages of 50 and 59 taking estrogen alone were not at increased risk of heart attacks (Archives of Internal Medicine, February 13, 2006►. These women had previously undergone hysterectomies, so they did not need progesterone.
Estrogen alone is not safe for a woman who still has her uterus since it increases the risk of endometrial cancer. Progestins like Provera protect against this kind of cancer. When added to estrogen, however, they may increase the risk of heart attacks and strokes and possibly breast cancer as well. For some women, progesterone lowers libido and leads to depression.
Doctors have followed the practice of prescribing progestin along with postmenopausal estrogen for many years, since research determined that estrogen alone increased the risk of cancer of the lining of the uterus (the endometrium). Endometrial cancer is not an issue for women with no uterus, and in the WHI study, these women were randomized to Premarin (estrogen alone) or placebo. This works just fine for hot flashes. Don’t count on it to provide any cardiac benefits, though. Overall, women in the WHI study were not protected from heart attack or stroke by HRT whether they took Prempro or Premarin alone.32
Some critics of the WHI have objected to the use of Premarin or Prempro, and suggested that other forms of postmenopausal estrogen replacement therapy would be preferable. There aren’t studies to prove or disprove that idea. Epidemiologists at Group Health Cooperative, a big health maintenance organization in Washington, compared rates of heart attack and stroke among women taking Premarin and those taking another form of estrogen such as Estratab or Menest. They found a hint that the other forms of estrogen might be somewhat less likely to trigger a heart attack or stroke, but these data need to be confirmed.733
Bioidentical Hormones
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Q. I am a family physician. Back when we were prescribing HRT regularly, I used to offer women the option of plant-based estrogens instead of synthetic hormones. Since we learned the results of the Women’s Health Initiative (WHI), though, I’ve viewed all estrogens as carrying similar risk until proven otherwise.
There are practitioners who are saying that bioidentical hormones are safer. They encourage women to use them as an alternative for treating menopausal symptoms. Is there any research that shows that the risks are lower for plant-based HRT than for synthetic?
A. There is no comparable study of plant-based estrogens, and there is not likely to be one. The WHI was a very large and expensive study funded by the National Institutes of Health. Women were randomly assigned to receive Prempro or placebo. The results showed that postmenopausal hormones increased the risk of breast
cancer, heart attack, and stroke.
Women’s health expert Susan Love, MD, responded
to a question like yours: “I think that it is very unlikely that bioidentical hormones, as they’re called, will be any safer than Prempro.”
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The American College of Obstetricians and Gynecologists (ACOG) came out with a very strong caution about bioidentical hormones in 2005. Michele Curtis, MD, is associate professor of obstetrics and gynecology at Houston’s University of Texas Medical School. On behalf of ACOG she said. “There are a growing number of women who are seeking therapy with bioidentical hormones, but there is a lot of misinformation about the assertion that these are plant-derived and therefore more closely mimic the estrogen that is in a woman’s body….. These are hormones. They act just like estrogens that are 34    commer-
cially produced.,,7
The obstetricians and gynecologists of ACOG are concerned that plant-based hormones are unregulated and, as a result, women may not be informed about risks. In addition, lack of oversight may mean that it is hard to guarantee quality. Many of these products are made in small compounding pharmacies that act like micro–drug companies but escape the kind of regular FDA inspections one might expect a bigger manufacturer to undergo. When the FDA did check on samples from 12 compounding pharmacies, ACOG reports that “34 percent of them failed one or more standard quality teStS.!,131
Progesterone
Kau Nwmnwe intrigued by the possibility that a progesterone cream derived from plant sources can be applied to the skin to relieve hot flashes naturally. Although wild yam can be used as a raw material for the manufacture of progesterone-like compounds, the human body can’t convert wild yam to progesterone. A controlled study suggests that a cream containing wild yam extract is not much better at reducing hot flashes than a placebo.736 Other creams formulated to contain progesterone can provide a dose comparable to taking progesterone by mouth.”‘ Progesterone pills or long-lasting injections such. as Depo-Provera can ease hot flashes, but questions remain about the long-term safety of this hormone for postmenopausal women. 738
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0. A nasty divorce has left me feeling slightly depressed, despite the relief of being out of a bad marriage. At times my heart races and then I break out in a sweat. I don’t know if these episodes are just anxiety or if they are hot flashes, since I am menopausal.
I am reluctant to take estrogen because I’ve heard about negative effects. IV rather use a more natural approach. Would a progesterone cream be safe?
A. Many women experience hot flashes much as you have described them, with an accelerated heart rate, a vaguely anxious feeling, sweating, and feeling too warm. Progesterone cream may help reduce hot flashes. Women’s health expert Susan Love, MD, points out, however, that high levels of progesterone are not natural after menopause. She worries that potential side effects might arise with long-term progesterone use. In addition, progesterone has been linked to depression.