Menopause and Perimenopause

Menopause is a natural change that doesn't require treatment. But symptoms of hormonal change can be difficult. If you have insomnia, mood swings, hot flashes, cloudy thinking, heavy menstrual periods, or other menopause symptoms, treatment can help you manage this transition more comfortably. As you review your options, consider the following:

• Healthy lifestyle habits will help you reduce menopause symptoms. These habits include eating a balanced diet; reducing stress; getting regular exercise; and avoiding smoking, heavy caffeine, and heavy alcohol use. An unhealthy lifestyle can make symptoms worse.
• Low-dose hormone therapy (HT) or low-dose birth control pills may be an option if you are still having periods and have multiple or severe symptoms. Birth control pills aren't used after menopause because they contain higher levels of hormones than women need.
• After menopause, hormone therapy can be used as a short-term treatment for severe symptoms when taken in as low a dose as possible.
• You may only need a specific treatment for certain symptoms, such as hot flashes or vaginal dryness.
• Meditative breathing or supplements such as black cohosh or soy may help relieve symptoms.

Research has led to a big change in how doctors use hormone therapy after menopause. For a long time, estrogen-progestin, or hormone replacement therapy (HRT), was thought to protect against heart disease or dementia. But studies now show that HRT use can cause serious health problems in a small number of women. These health problems include dangerous blood clots, stroke, heart disease, breast cancer, ovarian cancer, and dementia.^{5, 6, 7} The heart disease risk does not seem to affect women during their first 10 years after menopause.⁸

Average HRT- and ERT-related risks are low among the general population of women. But your personal risk that hormone therapy may stimulate breast cancer, ovarian cancer, cardiovascular problems, blood clots, or neurological changes may be lower or higher, depending on your risk factors for those health problems.

Treatment options for menopause symptoms

Hot flashes.Meditative breathing exercises (paced respiration) have been shown to reduce hot flashes.⁹ Medicines that can improve hot flashes include short-term, low-dose hormone therapy, antidepressants, the high blood pressure medicine clonidine, and the antiseizure medicine gabapentin (Neurontin).^{10, 11}

Heavy periods. The hormone progestin can help relieve heavy menstrual bleeding caused by very low or very high progesterone levels (after you have an exam to rule out other possible causes). Other options include nonsteroidal anti-inflammatory drugs (NSAIDs), the levonorgestrel (LNg) IUD, or birth control pills. For severe blood loss, some women choose permanent surgical treatment. These options include removing the uterus (hysterectomy) or using heat energy to damage and scar the wall of the uterus (endometrial ablation). For more information, see the topic Dysfunctional Uterine Bleeding.

Vaginal dryness and irritation. A vaginal lubricant can help with dryness. Low-dose vaginal estrogen can help if your symptoms are thin skin, dryness, and/or irritation. Less estrogen is absorbed into your system with vaginal use, so the risks associated with ERT are less likely.

Multiple or severe symptoms.Hormone therapy can relieve multiple or difficult menopause symptoms. For symptom relief before menopause, low-dose estrogen-progestin birth control pills or low-dose HRT (estrogen-progestin) can reduce heavy menstrual bleeding and other symptoms. After menopause, low-dose HRT is an option. Also, for severe symptoms that don't improve with estrogen-progestin, there is an estrogen-testosterone therapy. But testosterone is not FDA-approved for women, because it is not yet well studied. Talk to your doctor about short-term HRT along with checkups every 6 months.

Bioidentical hormone replacement therapy (BHRT) is an alternative to HRT. But it has not been well studied. The hormones are made in a laboratory from wild yams or soy. BHRT is thought to be more similar to human-produced hormones than synthetic HRT is. (Well-designed studies have not yet proved this theory.¹²) But bioidentical HRT may carry the same heart, stroke, blood clot, breast cancer, ovarian cancer, and dementia risks that are linked to traditional HRT. Any form of hormone therapy, including BHRT, is best taken for as short a period as possible after menopause.

Should I use hormone replacement therapy (HRT)?

Testosterone is sometimes used to increase sexual desire in postmenopausal women who have low testosterone. But the U.S. Food and Drug Administration (FDA) has not approved testosterone treatment for this purpose. There is no testosterone product that comes in doses that are right for women. Studies of testosterone in women have not lasted longer than 6 months.¹³ FDA experts want to know more about long-term risks before they approve testosterone for use by females.

If you have a problem with low sexual desire, consider that most sexual problems in women relate to such things as relationship troubles, depression, or medicine side effects. For more information, see the topic Sexual Problems in Women.

Other treatment options

Women may also try alternative medicine to relieve menopause symptoms. These alternatives may include black cohosh (Remifemin) or dietary soy. For more information about alternative treatments, see the Other Treatment section.