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Updated US guidelines on treating menopause

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New US guidelines for the treatment of menopause symptoms confirm that systemic hormone therapy is the most effective approach, but there is growing evidence to support non-hormonal treatments, and it is important that all therapy be tailored to the individual.

The advice comes in the updated Practice Bulletin of The American College of Obstetricians and Gynecologists, and refers to the treatment of hot flushes and vaginal dryness in menopausal women.

Dr Clarisa Gracia, Associate Professor of Gynaecology and Obstetrics at the Perelman School of Medicine, University of Pennsylvania, told Medscape Medical News (MMN) that the 2014 Practice Bulletin gives new drug information, but identifies no new risks or dangers.

“While the hormone therapy recommendations are similar to prior recommendations, there is more evidence to support non-hormonal alternatives … for the management of vasomotor symptoms,” Dr Garcia said.

Those alternatives include selective serotonin re-uptake inhibitors, selective norepinephrine re-uptake inhibitors, clonidine and gabapentin.

“In addition, the document updates newer agents that combine selective oestrogen receptor modulators and oestrogen to reduce negative side effects,” Dr Garcia said.

“Additional long-term data are needed to determine risks associated with new agents.”

Hot flushes affect between 50 per cent and 82 per cent of US women who experience natural menopause, and between 10 and 40 per cent experience vaginal dryness, MMN reported. The Women’s Health Initiative study in the US showed that the major risks of hormone therapy are deep vein thrombosis and breast cancer. An American College of Obstetricians and Gynaecologists Committee Opinion from April 2013 found that giving hormone therapy via a skin patch was safer than with a tablet.

The latest Practice Bulletin points out what to avoid, saying progestin alone increases breast cancer risk, and testosterone provides no benefit (except improved sexual satisfaction), but comes with multiple risks.

It says there is too little evidence to support any benefit from compounded hormones, phytoestrogens, herbal remedies or exercise.

“Because all medications have potential side-effects and risks associated with their use, it is important to weigh the potential risks and benefits of treatment. Therapy should be individualised,” Dr Gardia told MMN.

The key recommendations from the updated Practice Bulletin include that: “Systemic hormone therapy, with just oestrogen or oestrogen plus progestin, is the most effective approach for treating vasomotor symptoms”.

It also recommends that low-dose and ultra-low systemic doses of oestrogen have less risk than standard doses, and that doctors should individualise care and use the lowest effective dose for the shortest duration.

While there is not enough data to support use of progestin alone, testosterone, compounded hormones, phytoestrogens, herbal supplements and lifestyle modifications, the Bulletin does promote “common sense lifestyle solutions” such as layering clothing, lowering room temperature and consuming cool drinks as ways to cope with hot flushes.

Debra Vermeer