Priority Topic: Menopause

Key Feature 5: When a patient has contraindications to hormone-replacement therapy (HRT), or chooses not to take HRT: Explore other therapeutic options and recommend some appropriate choices
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 6a: In menopausal or perimenopausal women: Specifically inquire about the use of natural or herbal products.
Skill: Clinical Reasoning, Selectivity
Phase: History

Key Feature 6b: In menopausal or perimenopausal women: Advise about potential effects and dangers (i.e., benefits and problems) of natural or herbal products and interactions.
Skill: Clinical Reasoning
​Phase: Treatment

Hormone replacement therapy used to scare people. Older studies showed there was a significantly greater risk of adverse cardiovascular outcomes for women at risk, but the women looked at in these studies were quite far along past the menopausal transition - in their 70s or so. Newer evidence has shifted current thinking, and with the advent of the estrogen patch to further decrease risk, many women are now candidates who were previously shunned from the benefits of hormone replacement therapy for the treatment of distressing menopausal symptoms. There are still some reasons, however, for which hormone replacement therapy is contraindicated, or for which symptoms are too mild to be considered worth it for the patient to start this treatment, or for women who do not want to assume the risks of hormone therapy that do exist even if relatively small, and women should be assisted to understand the other effective options that are available for the treatment of bothersome hot flashes and vulvovaginal atrophy. Explaining the other options that are available to treat menopausal symptoms is also indicated in obtaining good informed consent for hormone therapy, so women know there are other options to consider even if they present to clinic thinking this is what they want.

Below is the information I've amassed about non-hormonal therapy treatment options per UpToDate:

For women with mild hot flashes:

• "Women with mild flashes (hot flashes that do not interfere with usual activities) usually do not need pharmacotherapy. Instead, simple behavioral measures, such as lowering room temperature, using fans, dressing in layers of clothing that can be easily shed, and avoiding triggers (such as spicy foods, anxiety, warm drinks, caffeine, alcohol, stress, sudden ambient temp change), can help reduce the number of hot flashes."
• "Other potential options may include weight loss, cognitive behavioral therapy (CBT), vitamin E, and hypnosis."

For women with moderate to severe hot flashes:

• "The agents most commonly used include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), antiepileptics, and centrally acting drugs. These drugs are also often tried in women who experience recurrent hot flashes after stopping hormone therapy. Our choice of drug depends upon whether the patient is taking tamoxifen, the pattern of hot flashes, and the presence of a mood disorder or sleep problem." SSRIs tend to be first line because they have as much evidence for effectiveness as anything else and because by and large they have the least number and severity of side effects.

For women with vulvovaginal atrophy:

• "Vaginal atrophy (also referred to as vulvovaginal atrophy, urogenital atrophy, or atrophic vaginitis) caused by estrogen loss often results in vaginal complaints (ex: dryness, burning, dyspareunia) that cause distress in menopausal women. Urinary frequency and recurrent bladder infections may also occur. (...) As first line therapy for symptoms of vaginal atrophy, we suggest regular use of vaginal moisturizing agents supplemented by water-based lubricants during vaginal intercourse rather than treatment with hormonal agents." So the first-line therapy for this symptom specifically, in the absence to treat other symptoms of menopause, is not even hormone therapy anyway! 

Many women who are bothered by the symptoms secondary to menopause may already be trying their own alternative herbs remedies. It is important to ask about this, as there are a lot of natural remedies that women use. Furthermore, if something is strong enough to have an impact on symptoms, it's certainly possible to be having side effects and it's worth keeping on your radar as their physician, as for any patients in general who take herbal supplements. Like fad diets, there is no shortage of herbal remedies purported to treat symptoms and disease processes. Sometimes the evidence is in favour of them, sometimes it is not, and sometimes it is inconclusive. While training to learn the basics of Family Medicine and the number of medications and all of their possible side effects and risks, recommended dosages and drug interactions, I simply cannot prioritize taking on the vast compendium of herbal therapies out there in the ether. However, it is my duty to look things up as patients inquire or confide in me that they are using them, and then to counsel them on what is known based on the evidence that is available. Although I can't be expected to be aware of treatments that are uncommon and that I don't personally prescribe or recommend, helping patients to make choices that are as informed as possible, while taking into account their values and preferences, is always my role as their family physician.