A New Practice Bulletin For The Treatment Of Menopause Has Been Released.
The American College of Obstetricians and Gynecologist has updated their practice bulletin (published in Jan 2014 Obstetrics & Gynecology journal) for how to treat hot flashes and vaginal atrophy. I was interested in seeing how these regulations are similar to, or are different from, the British Menopause Society’s updates done in May 2013.
When it comes to the hormones, it is a difficult choice for patients and doctors to make as each one of us will respond differently to different treatments. This is because what works for one person will not always work for the next person.
This new bulletin will replace the June 2001 version. And, according to Clarisa Garcia, MD who helped to develop the recommendations, there are no new risks, or dangers, with the new drug information. What they are stating is as follows:
"While the hormone therapy recommendations are similar to prior recommendations, there is more evidence to support non-hormonal alternatives such as [selective serotonin reuptake inhibitors] and [selective serotonin and norepinephrine reuptake inhibitors] for management of vasomotor symptoms. In addition, the document updates newer agents that combine [selective estrogen receptor modulators] and estrogen to reduce negative side effects. Additional long-term data are needed to determine risks associated with new agents," said Dr. Gracia to Medscape Medical News. Paroxetine is the only such drug approved by the FDA for menopause symptoms.
What they are saying is that doctors can use antidepressant medications to help with menopausal issues. However, some of my patients have told me that they have been given these medications for menopause with less than desired results in the past. Often my patients do not want them, or when they take them they do not feel any benefits as they are not getting to the root cause of the issue.
Through the Women’s Health Initiative study, we doctors have found that the major risks associated with oral hormone therapy (HT - conjugated equine estrogen and medroxyprogesterone acetate) are breast cancer and venous thromboembolism. The new bulletin that American College is putting out states that transdermal application is safer than oral administration of HT. I agree that topical application is safer. However, I do not approve of the hormones they are using. The bulletin goes on to list two drugs approved by the FDA: “bazedoxifene instead of progestin with conjugated estrogen for hot flashes and osteoporosis prevention, and ospemifene for vaginal dryness that may cause dyspareunia [painful intercourse],” for use.
So if you are a doctor then this is essentially how you are supposed to approach the patients condition under the American Colleges guidelines:
- Level A ("good or consistent scientific evidence"):
- Systemic HT, with just estrogen or estrogen plus progestin, is the most effective approach for treating vasomotor symptoms.
- Low-dose and ultra-low systemic doses of estrogen have a more favorable adverse effect profile than standard doses.
- Healthcare providers should individualize care and use the lowest effective dose for the shortest duration.
- Thromboembolic disease and breast cancer are risks for combined systemic HT.
- Selective serotonin reuptake inhibitors, selective serotonin and norepinephrine reuptake inhibitors, clonidine, and gabapentin relieve vasomotor symptoms and are alternatives to HT.
- Local estrogen therapy is advised for isolated atrophic vaginal symptoms.
- The only non-hormonal therapy approved to treat vasomotor symptoms is paroxetine, and to treat dyspareunia is ospemifene.
- Level B conclusions ("limited or inconsistent scientific evidence"):
- Data do not support use of progestin alone, testosterone, compounded bioidentical hormones, phytoestrogens, herbal supplements, and lifestyle modifications.
- "Common sense lifestyle solutions" are layering clothing, lowering room temperature, and consuming cool drinks.
- Non-estrogen water-based or silicone-based lubricants and moisturizers may alleviate pain.
- Level C recommendation ("based primarily on consensus and expert opinion"):
- Individualize the decision to continue HT.
As you can see if you compared them, these guidelines share a few things with the British Menopause Society’s guidelines. However, there are a lot of differences. The British guidelines are more focused on when to use hormones rather than other drugs that can be used with a quality of life focus.
This new bulletin also points out that, “too little evidence supports benefit of compounded bioidentical hormones, phytoestrogens, herbal remedies, or exercise.” Clinically these are often my first line treatment options for my perimenopausal, and menopausal patients. My patients tell me that they feel, and see, a decrease in their signs, and symptoms, associated with these changes in hormones under my mentioned first line therapies. They often tell me that they are back in control of their world. So I think there are many clinical benefits to what we, as naturopathic doctors, can offer when it comes to hormone balancing.
As with all of medicine, we have to focus on the individual, and tailor treatment that best covers a patient's individual needs; along with taking into account all risks, and benefits, associated with anything that we do for the patient.
Reference: Medscape (registration required)