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Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)

Patient education: Non-estrogen treatments for menopausal symptoms (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Oct 24, 2023.

INTRODUCTION — During the reproductive years, the ovaries produce estrogen and progesterone. Estrogen is important for normal menstrual periods and fertility, and it promotes bone strength. Estrogen and progesterone levels fall at the time of menopause (when monthly periods stop); this is what causes symptoms such as hot flashes.

"Menopausal hormone therapy" (MHT) is the term used to describe the two hormones (estrogen and progesterone) that are often given as a treatment to relieve menopausal symptoms. For people whose uterus has been removed (ie, who have had a hysterectomy), estrogen alone can be given. For others, both estrogen and progesterone are given. Experts recommend natural progesterone; synthetic forms are also available. Estrogen is the most effective treatment available to relieve bothersome symptoms of menopause. However, some people cannot take estrogen; for example, those with breast cancer. Other people choose not to take hormone therapy. Fortunately, there are some alternatives to hormone therapy to treat menopausal symptoms. Although they may not be as effective as estrogen, they do provide some relief.

This article discusses alternatives to MHT. The risks, benefits, and options for hormone therapy are discussed separately. (See "Patient education: Menopausal hormone therapy (Beyond the Basics)".)

CONTROLLING HOT FLASHES — Non-estrogen treatments for hot flashes are effective for many people. None work as well as estrogen, but they are better than no treatment. Some people only have mild hot flashes and do not need treatment. For those who do, options include:

Antidepressants — Antidepressant medications are recommended as a first-line treatment for hot flashes in people who cannot take estrogen.

SSRIs – The selective serotonin receptor inhibitors (SSRIs) are the class of antidepressants used most commonly for treating hot flashes. A form of paroxetine (sample brand name: Brisdelle) is an SSRI and is the only nonhormonal therapy that is specifically approved for hot flashes in the United States. This medication has been used for many years for treating depression, but it can be taken at a lower dose for hot flashes.

Although not approved for this use, other SSRIs such as citalopram (brand name: Celexa), and escitalopram (brand name: Lexapro) relieve hot flashes to similar degrees as is seen with paroxetine.  

People with breast cancer who are taking a drug called tamoxifen should not take paroxetine, as it can interfere with tamoxifen.

Other antidepressants – Antidepressants that are similar to SSRIs such as venlafaxine (brand name: Effexor) and desvenlafaxine (brand name: Pristiq) also reduce hot flashes, but they may have more side effects than the SSRIs.

Fluoxetine (brand name: Prozac) and sertraline (brand name: Zoloft) do not work as well as the other antidepressants listed.

More information about antidepressants is available separately. (See "Patient education: Depression treatment options for adults (Beyond the Basics)".)

Gabapentin — Gabapentin (sample brand name: Neurontin) is a medication that was developed to treat seizures. It also relieves hot flashes in some people. It may be taken as a single bedtime dose (if hot flashes are most bothersome at night) or can also be taken during the daytime.

Oxybutynin — Oxybutynin is a drug that is usually used to treat overactive bladder and urinary incontinence. It also has been demonstrated to be effective for treating hot flashes. The most bothersome side effect is dry mouth.

Fezolinetant — Fezolinetant (brand name: Veozah) is a nonhormonal medication that comes as a daily pill. Possible side effects include abdominal pain, diarrhea, back pain, and liver problems.

Progesterone — The injectable progestin birth control hormone medroxyprogesterone acetate (brand name: Depo-Provera) helps to reduce hot flashes about as well as estrogen; however, it is not commonly used due to side effects such as irregular vaginal bleeding, acne, headache, and depression.

Plant-derived estrogens (phytoestrogens) — Plant-derived estrogens have been marketed as a "natural" or "safer" alternative to hormones for relieving menopausal symptoms. Phytoestrogens are found in many foods, including soybeans, chickpeas, lentils, flaxseed, lentils, grains, fruits, vegetables, and red clover. Supplements containing isoflavone, a type of phytoestrogen, can be purchased in health food stores.

However, it is uncertain whether phytoestrogens help to reduce hot flashes or night sweats; most studies have not reported benefit. In addition, some phytoestrogens might act like estrogen in some tissues of the body. Many experts suggest that people who have a history of breast cancer avoid phytoestrogens.

Herbal treatments — A number of herbal treatments have been promoted as a "natural" remedy for hot flashes. Many people use black cohosh for hot flashes, but clinical trials have shown that it is not more effective than placebo. There have been concerns that black cohosh could stimulate breast tissue like estrogen, increasing the risk of recurrence in people who have had breast cancer. However, there is no convincing evidence that it is harmful, even in people with breast cancer. Still, some experts suggest that people with breast cancer avoid black cohosh until this has been studied more extensively. Herbal treatments are not recommended for hot flashes or other menopausal symptoms.

Mind-body and other treatments — Stress management, relaxation, deep breathing, and yoga might be helpful for some people, but study results have been inconsistent; however, these approaches are not likely to be harmful and may have other benefits. Other approaches such as hypnosis and acupuncture have also not been proven to reduce hot flashes, although some people find them helpful (possibly due to a placebo effect). A stellate ganglion blockade (numbing of a nerve in the neck with an injection) has been shown, in a number of small trials, to help hot flashes, but it is rarely done in practice.

TREATING VAGINAL DRYNESS — Low-dose vaginal estrogen is a very effective treatment for vaginal dryness or pain with intercourse due to menopause. This is a treatment that can be continued for many years after menopause because only minimal amounts get into the bloodstream. On this basis, low-dose estrogen is not thought to increase the risk of breast cancer, heart attack, or stroke. This, along with other treatment options for vaginal dryness, is discussed in more detail in a separate article. (See "Patient education: Vaginal dryness (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Menopause (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Menopausal hormone therapy (Beyond the Basics)
Patient education: Bone density testing (Beyond the Basics)
Patient education: Osteoporosis prevention and treatment (Beyond the Basics)
Patient education: Calcium and vitamin D for bone health (Beyond the Basics)
Patient education: Vitamin D deficiency (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)
Patient education: Diet and health (Beyond the Basics)
Patient education: High cholesterol and lipids (Beyond the Basics)
Patient education: Depression treatment options for adults (Beyond the Basics)
Patient education: Vaginal dryness (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Overview of androgen deficiency and therapy in females
Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis
Estrogen and cognitive function
Menopausal hot flashes
Menopausal hormone therapy and cardiovascular risk
Menopausal hormone therapy and the risk of breast cancer
Menopausal hormone therapy in the prevention and treatment of osteoporosis
Menopausal hormone therapy: Benefits and risks
Preparations for menopausal hormone therapy
Treatment of menopausal symptoms with hormone therapy
Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment

The following organizations also provide reliable health information.

Hormone Health Network

(www.endocrine.org/patient-engagement/endocrine-library/menopause)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Richard Santen, MD, who contributed to earlier versions of this topic review.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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