Gabapentin (Neurontin)isa γ-aminobutyric acid analogue approved for the treatment of seizures that reduced hot ﬂash frequency and severity significantly more than placebo in several randomized, double-blind trials (24). Hot ﬂash scores decreased 54% in the women treated with gabapentin (900 mg per day) compared with a 31% reduction in placebo-treated women. Side effects include disorientation, dizziness, and drowsiness. Women who are principally bothered by night sweats and disrupted sleep may benefit from sleeping medication. In a double-blind, placebo-controlled study of peri-and postmenopausal women, the prescription insomnia treatment, eszopiclone, significantly improved sleep and menopause-related symptoms, with a positive impact on next-day functioning, mood, and quality of life (25). The antihistamine diphenhydramine hydrochloride is an inexpensive, over-the-counter sleep aid.
Urogenital Atrophy Urogenital atrophy results in vaginal dryness and pruritus, dyspareunia, dysuria, and urinary urgency. These common problems in menopausal women respond well to therapy (26). Systemic estrogen therapy is a very effective treatment for vaginal dryness, dyspareunia, and associated symptoms. Low doses of estrogen applied vaginally are preferred to systemic estrogen therapy when vasomotor symptoms are not present, given minimal systemic absorption and increased safety. Low doses of estrogen cream (Premarin, Estrace) (0.5 g) are effective when used only once or twice a week (27). An estradiol vaginal tablet (Vagifem) (10 μg) inserted twice weekly may be less messy and easier to use than estrogen cream. An estrogen-containing vaginal ring (Estring) (7.5 μg per day) is another convenient formulation, which is placed in the vagina every 3 months and slowly releases a low dose of estradiol (28). Studies of the low-dose estrogen vaginal ring and tablet confirm a small increase in serum estradiol and estrone levels, but these levels remain within the normal range for postmenopausal women (29).
Studies of the vaginal tablets and ring of up to 1 years’ duration confirmed endometrial safety, but long-term studies on the effects of low-dose vaginal estrogen therapy on the endometrium are not available. Women using vaginal estrogen therapy should be reminded to report any vaginal bleeding, and a thorough evaluation should be performed. Typically, concurrent progestin therapy is not prescribed with low-dose vaginal estrogen preparations. Long-acting vaginal moisturizers, available without a prescription, are an effective nonhormonal alternative for treating symptoms of urogenital atrophy when used two to three times weekly (e.g., Replens, KY-Long Acting). Nonhormonal vaginal lubricants (e.g., Astroglide, KY-Silk) increase comfort with intercourse.
Vaginal estrogen therapy appears to reduce urinary symptoms, such as frequency and urgency, and reduces the likelihood of recurrent urinary tract infections in postmenopausal women (30). The effect of estrogen therapy on urinary incontinence is unclear. Whereas the results of some studies suggest improvement in incontinence with estrogen therapy, others show a worsening of symptoms (31).