Finding the Right Treatment Regimen for Menopause

There have been many changes in the way we prescribe estrogens and progestins. These methods are referred to by doctors as treatment regimens or treatment protocols. They range from taking the hormones alone to taking them in various combinations with another hormone; from taking them continuously to receiving treatment in cycles that involve time on and off the medication. Learning about the various regimens and why and how we select them can help you understand why you may be taking hormones every day, whereas your best friend takes them cyclically.

Cyclic Regimen

Estrogen used alone, either cyclically or continuously, has been as­sociated with an increase in the risk of uterine cancer. For this reason, we add progesterone or progestin. (The progestin inhibits the growth stimulation of estrogen.) The combination of estrogen and progestin, taken cyclically, is the most popular method of HRT today.

The cyclic treatment most frequently prescribed works in accord with the calendar month. You take estrogen from the first through the twenty-fifth day of the cycle, adding progestin for the last twelve or thirteen days of the estrogen therapy, and then stop both medications for the final days of the month. Withdrawal bleeding may occur at the end of the month during the pill-free days.

There are three cyclic methods popularly in use in the United States today:

– You take estrogen tablets on days one to twenty-five of the month and add progestin for approximately twelve days (days fourteen to twenty-five). ,

– You use the estrogen patch, changing it twice weekly for twenty-five days and take oral progestin on days fourteen to twenty-five.

– You take one of the other estrogens and progestins in equivalent doses and cycle twenty-one days on and seven days off therapy.

These methods have one thing in common: About two-thirds of those women who have their uterus intact will experience a period during the treatment-free days. The amount of bleeding usually lessens over time and, after several years, may disappear altogether.

Continuous Therapy

Continuous therapy involves the uninterrupted use of estrogen. Re­cent prescribing trends have moved away from the interrupted, or cycled, use of estrogen, which actually rests on little scientific founda­tion.

Continuous estrogen with intermittent progestin has become the most popular U.S. method of continuous therapy. It works this way: You take estrogen continuously, either as a daily tablet or as a skin patch changed twice each week. You take progestin on the first twelve days of the calendar month.

More than two-thirds of women with an intact uterus will, on this regimen, experience bleeding. Bleeding, however, should occur only after the twelfth day when the progestin is stopped and last until around the sixteenth day. If bleeding occurs before the ninth of the month, it may suggest that the dose of the progestin is too low and should be adjusted. Bleeding starting after the sixteenth day should be considered irregular and reported to your physician.

Combined Continuous Therapy

Combined continuous therapy is a more innovative method of hor­mone replacement. This therapy involves daily doses of estrogen combined with low daily doses of progestin. The combined continu­ous method attempts to avoid that most unpopular side effect of HRT, withdrawal bleeding, that usually occurs with cyclic therapy. Variable results of this therapy have been reported in recent medical literature.

Endometrial sampling (biopsy) is often required, which generally shows a mixed pattern of estrogen and progestin in the uterine lining. Most women do not like the irregular bleeding and stop taking therapy. Those who continue usually find that they stop bleeding after approximately six months.

Is it worth it? Further research is necessary in order to answer this question. It seems likely that this form of combined continuous ther­apy may become very popular in the future. The main hesitation in prescribing it now is the risk of giving the body too much progestin, with a possible risk of heart disease or breast disease as a result.

Continuous Progestin Therapy

Progestin only, taken continuously, is a form of therapy for women who cannot take estrogen because they have had breast or uterine cancer, or because they have severe fibrocystic breast disease. Women take it either daily in pill form or in monthly intramuscular shots.

Progestins help to prevent osteoporosis. Their protection of bone, however, is not as good as that of estrogen. The major disadvantage of progestin-only therapy is that it may increase the risk of heart disease.

Nonhormonal Treatments for Menopausal Symptoms

Although your body responds best to hormones and should be treated with them, if possible, nonhormonal drugs can play a role in offering relief from midlife discomforts. If you cannot take hormones for the reasons outlined below, however, there are other means of treatment that can be considered. We want to offer a word of caution here. It is important that you and your doctor investigate any symptoms that you have to try to learn their specific causes. If you have symptoms that may be caused by psychological or sociocultural factors, perhaps they ought to be treated with an educational or a psychosocial thera­peutic approach. In such a case, drugs would be an adjunct to other forms of therapy.

It is important as well that you receive treatment that is symptom-specific. Be careful with yourself. Don’t assume that all the symptoms that you have are related to menopause just because you are experi­encing menopause. Guided by your own introspection, and by the results of clinical tests, work with your physician to decide what’s what!

Even though nonhormonal drugs are not primary sources of relief for menopausal discomforts, your doctor might advise you to take them in the following situations:

– If you cannot use HRT for medical reasons

– If you do not get relief from HRT

– If you do not want HRT, but do want symptom relief

– If you cannot tolerate HRT because of side effects, such as nausea or fluid retention

It can be difficult to select the right nonhormonal drug for the treatment of climacteric problems. Often the physician’s choice rests more on guesswork than on the proven effects of treatment, as there are not enough studies that document conclusively the therapeutic efficacy of nonhormonal drugs.

As editor of the medical publication Maturitas, Dr. Utian analyzed the articles published over an eight-year span and discovered that more than 90 percent were about the use of hormones compared to fewer than 10 percent about the efficacy of nonhormonal medications. Further, in nine out of ten of the articles on nonhormonal medica­tions, physicians reported more side effects than benefits with these medications. Although very few nonhormonal medications currently available effectively combat climacteric syndrome problems such as hot flashes, some may work, and you should be aware of them.

There are seven kinds of nonhormonal medications. They include the following:

– Sedatives (for sleep)

– Tranquilizers (to induce calmness)

– Antidepressants

– Clonidine

– Propranolol

– Vitamin B6 (pyridoxine)

– Vitamin E

Sedatives may reduce the number of hot flashes you endure, but are less helpful in relieving irritability and emotional upset. Phenobarbital USP, alone or in combination with other drugs, seems to be effective and is available commercially as Bellergal tablets. However, sedatives are less effective than HRT in reducing menopause problems.

Tranquilizers comprise a large group of drugs that are often abused in the care of postmenopausal women when they are prescribed before HRT. When chosen as an appropriate treatment method, monitored, and used with educational and psychotherapeutic pro­grams—only if the “agitated states” are not biologically caused—they are helpful for women with excessive anxiety, irritability, insomnia, and related agitated states. The most often prescribed tranquilizers are Valium, Librium, Ativan, Xanax, Buspar, and some of the phenothia-zines.

Antidepressants are prescribed for the same reasons as tranquilizers; however, they are used in cases of severe depression. Among the most commonly used are Elavil, Nardil, Parnate, Sinequan, and Tofranil.

Clonidine has received attention because of its helpfulness in com­bating hot flashes. At first, it was manufactured in low dose as an antimigraine drug; and later it was made in high dose as an antihyper­tensive drug. Then, doctors reported that it appeared to reduce perimenopausal flushing. Some studies support this observation; oth­ers do not, but there is reason to hope that further research will find a nonhormonal treatment for hot flashes.

Propranolol (Inderal) is another drug that was studied for its effect on hot flashes, but it has not been found effective.

Vitamin B6 is sometimes suggested, because there is some evidence that the loss of sex hormones may cause a deficiency in this vitamin. Symptoms of such deficiency may include depression, emotional insta­bility, fatigue, disturbances in concentration, and loss of libido. These symptoms may respond to 50-200 milligrams of vitamin B6 taken daily. Do not take megadoses: The side effects may include altered tryptophan metabolism (tryptophan is the amino acid that maintains” normal nitrogen equilibrium in the body), which can be worse than the original problem.

Vitamin E, taken in megadoses, has gathered more than its share of claims for the relief of hot flashes. Many women claim relief, yet with careful comparative testing the vitamin did not pass the effectiveness test. As with other substances, anything taken in excess is risky busi­ness. I do not recommend megadoses of vitamin E, because liver problems may result.