Lifestyle interventions may safely decrease vasomotor symptoms. Being in a cool environment is associated with fewer subjective and objective hot ﬂashes, so women experiencing symptoms should be advised to keep the room temperature low and wear light, layered clothing (7). Overweight women and those who smoke have more severe vasomotor symptoms than women of normal weight and nonsmokers. These findings provide additional reasons to encourage women to lose weight and stop smoking (8,9).
Many menopausal women are interested in trying complementary and alternative (CAM) therapies for relief of hot ﬂashes. These are diverse medical and health care products and practices generally not considered part of conventional medicine. Vasomotor symptoms are particularly sensitive to placebo treatments, and numerous nutritional supplements and other interventions claim to relieve hot ﬂashes but are rarely studied in controlled trials (10). Phytoestrogens are plant-derived substances that may act as estrogen agonists-antagonists, with their effects modulated through interactions with the estrogen receptor. Although they decrease hot ﬂash severity and frequency, symptom improvement is similar to that seen with placebo treatment (11). Black cohosh is another popular alternative treatment, with efficacy likely similar to that of placebo (12). Although often recommended, vitamin E (800 IU per day) only minimally reduced hot ﬂashes in a placebo-controlled, randomized, crossover trial (13).
Acupuncture reduced vasomotor symptoms in several studies, although a traditional Chinese medicine approach may be no more effective than shallow or “sham” needling techniques (14). Exercise and paced respiration demonstrated an improvement in hot ﬂashes in several uncontrolled studies, with additional health benefits, including stress reduction. Women may choose to use alternative and complementary therapies for relief of symptoms, but they should be aware that the safety and efficacy of these approaches often are unproven.
Systemic estrogen therapy is the most effective treatment for vasomotor symptoms and the only therapy currently approved by the U.S. Food and Drug Administration (FDA) for this indication (see Table 34.1 for available hormone therapy formulations). Although standard doses are usually effective, younger women and those with recent oophorectomy may require higher doses. Healthy, nonsmoking women in the perimenopausal transition who are experiencing bothersome hot ﬂashes but still menstruating may benefit from oral contraceptives. The supraphysiologic doses of estrogens and progestins in oral contraceptives effectively treat vasomotor symptoms and provide cycle control. Low-dose estrogen therapy
Table 34.1 Hormone Therapy Options
Table 34.1 Continued 17β-estradiol (E) + levonorgestrel (P) Climara Pro 0.045 mg E + 0.0015 mg P once weekly
E, estrogen; P, progestin. Products available in the United States. Table modified and used with permission; North American Menopause Society; www.menopause.org.
also effectively treats hot ﬂashes for many women. Low-dose oral esterified and conjugated estrogens (CE) (0.3 mg daily), oral estradiol (0.5 mg daily), and transdermal estradiol (0.025 and 0.014 mg weekly) often are effective and associated with minimal side effects and endometrial stimulation (15–17). Progestin therapy must be given concurrently if a woman has not had a hysterectomy, although with low-dose estrogen therapy, intermittent progestin treatment may be an option.
Given the known risks, described in detail later in this chapter, hormone therapy should be used at the lowest effective dose for the shortest amount of time that meets treatment goals. The majority of healthy women with very bothersome hot ﬂashes at the time of the menopausal transition will benefit from short-term therapy and be able to wean off hormones after several years of use.