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The Treatment of Climacteric SymptomsPeri- and postmenopausal women commonly suffer from climacteric symptoms. In this article, we provide information to help physicians recognize climacteric steroid hormone replacement therapy and treat them appropriately. The information presented here is based on a selective search replacemeent the literature for pertinent articles that appeared from to earlyincluding the German S3 guideline on hormone therapy HT during and after menopause, which was published in Perimenopausal women often suffer from climacteric symptoms. Typically, women undergoing menopause complain of heat waves and vaginal dryness. According to steroid hormone replacement therapy controlled trials as well as national and international guidelines, HT is the most effective treatment for vasomotor symptoms and also improves vulvovaginal atrophy; for the latter indication, HT is preferably administered anabol steroid price. Vaginal estrogen therapy lowers the frequency of recurrent urinary tract infections.
Peri- and postmenopausal women commonly suffer from climacteric symptoms. In this article, we provide information to help physicians recognize climacteric symptoms and treat them appropriately.
The information presented here is based on a selective search of the literature for pertinent articles that appeared from to early , including the German S3 guideline on hormone therapy HT during and after menopause, which was published in Perimenopausal women often suffer from climacteric symptoms. Typically, women undergoing menopause complain of heat waves and vaginal dryness.
According to randomized controlled trials as well as national and international guidelines, HT is the most effective treatment for vasomotor symptoms and also improves vulvovaginal atrophy; for the latter indication, HT is preferably administered locally. Vaginal estrogen therapy lowers the frequency of recurrent urinary tract infections. However, HT is associated with an increased risk for a number of diseases, including stroke, thromboembolic events, gall-bladder diseases, and breast cancer.
Alternative treatments for climacteric symptoms have little or no efficacy. HT should only be used to treat climacteric symptoms after extensive patient education about its benefits and risks.
Participatory decision-making is desirable. The generalized use of HT by all women with climacteric symptoms cannot be recommended. Peri- and postmenopausal women often seek medical help, and climacteric symptoms are their most common reason for doing so. These symptoms are due to changes in ovarian function during the menopause. The transition from full ovarian function in the premenopausal period to a complete lack of ovarian estrogen synthesis in the postmenopausal period is, fundamentally, a normal aspect of human physiology, but specific disturbances or diseases may develop as a result of diminished estrogen synthesis.
Moreover, the peri- and postmenopausal periods are marked by psychosocial and other age-related changes that can also cause certain physical symptoms. A rational approach to climacteric symptoms per se requires a well-founded knowledge of the specific physiological and pathophysiological changes affecting women at this time in their lives. A number of treatments are available; a commonly used one is peri- and postmenopausal hormone therapy HT with sex steroids.
There has been a search for alternative treatments, particularly in recent years. In this review, we will discuss the main types of climacteric symptoms and their treatment. We will direct our attention primarily to HT, as it is clearly the most effective treatment available today.
Readers of this article should gain knowledge of the following aspects of the treatment of climacteric symptoms:. There are a number of ways to treat climacteric symptoms. Hormone therapy with sex steroids is a common form of treatment in the peri- and postmenopausal periods.
The retrieved publications are discussed in the text of this article if they contain information that is relevant to the topic of the article, as defined above. The state of scientific knowledge based on publications up to has already been taken into account in the creation of the German S3 guideline on hormone therapy HT in the peri- and postmenopausal periods 1 , 2 , e1. This systematic search and assessment of scientific evidence was performed in relation to climacteric symptoms, quality of life, urogenital symptoms, the musculoskeletal apparatus, bone metabolism, cardiovascular diseases, other diseases and aging processes, CNS diseases, cancer, premature ovarian failure, and alternative treatments.
A detailed description of the manner of testing and assessing the scientific evidence can be found in the methods report accompanying the S3 guideline. The guideline contains position statements that were issued on the basis of an evaluation of the evidence followed by a consensus-building process. These statements, in turn, provided the basis for the clinical recommendations that were derived from them. Perimenopausal women report so-called climacteric symptoms with varying frequency 1 — 3 , e1.
Some of these are clearly attributable to the reduced synthesis of sex steroids e. The constellation of symptoms is often designated the climacteric syndrome; there is, however, no uniform definition of this syndrome. Many cohort studies and cross-sectional studies have been performed for the purpose of characterizing climacteric symptoms 4 — 8 , e2 , e3. The ones most consistently found were hot flashes and vaginal dryness. Further symptoms such as sleep disturbances, bodily symptoms of various kinds, urinary tract symptoms, sexual problems, and mood changes were less consistently present Box 1.
The duration of hot flashes in relation to the beginning of menopause was the subject of a recently published cohort study of initially premenopausal women aged 35 to The mean duration of moderate to severe hot flashes was An overall assessment of the available studies provides no clear answer to the question whether women have a worse quality of life during this phase of their lives.
The quality of life, however, was not uniformly defined from study to study, and women with and without vasomotor symptoms were included in the analysis. Clinical experience clearly shows that women who suffer from these symptoms to a major extent consider their quality of life to be markedly reduced.
This is why they seek treatment. Because HT has certain risks, there has been a search for other treatments, particularly with drugs.
Preparations of botanical origin are especially popular. There have been many trials on the treatment of climacteric symptoms with phyto-estrogens in the form of isoflavone from red clover or soya and Cimicifuga racemosa. Most of the placebo-controlled trials have failed to show any significant reduction of vasomotor symptoms 9 , although some did reveal a small effect. Urogenital symptoms were not improved. In particular, nothing is known about the long-term safety of these preparations.
For these reasons, phyto-estrogens and other botanical and non-hormonal alternatives to hormone therapy cannot be recommended. A number of changes in lifestyle can, to some extent, improve mild vasomotor symptoms. This is suggested mainly by data from observational studies. Hot flashes can be reduced by low ambient temperatures. Women with a higher body-mass index were once thought to have less frequent hot flashes because of greater aromatization of androgens in adipose tissue, but recent studies have shown that they actually have more frequent hot flashes; thus, weight reduction down to a normal body weight is desirable.
Non-smoking women suffer from hot flashes less commonly than smokers. Regular physical exercise, too, can improve hot flashes.
Relaxation exercises have a beneficial effect on the frequency and intensity of hot flashes e4. Women for whom hormone therapy is contraindicated, such as women with breast cancer, are in a special situation. The selective serotonin reuptake inhibitors venlafaxine and fluoxetine have been found effective against vasomotor symptoms; on the other hand, there is no clear evidence for the effectiveness of the antihypertensive agents clonidine and methyldopa in this context.
Gabapentin, an anticonvulsant, has been found to have a beneficial effect on climacteric symptoms. The medications mentioned here as effective have not been approved for the treatment of climacteric symptoms.
It would seem appropriate to use them off label, after sufficient patient education, in cases where hormone therapy is contraindicated 1 , 2 , e1. In non-hysterectomized women, combined estrogen-gestagen therapy EPT must be administered instead of estrogen therapy alone ET in order not to elevate the risk of endometrial hyperplasia and endometrial carcinoma.
Both oral and transdermal preparations of EPT are available Box 2 ; natural progesterone can also be administered vaginally. Either progesterone derivatives or norethisterone derivatives C or C steroids, respectively can be used; these may have different partial effects, and one or the other can be chosen for use accordingly. Combined estrogen-gestagen therapy is administered either sequentially, with at least ten days of gestagen administration per month, or continually in combination.
A seven-day hormone-free interval as in oral contraceptive therapy is no longer recommended, as it often leads to a worsening of symptoms.
Various estrogens are used to treat climacteric symptoms. Estradiol, estradiol valerate, estriol, estriol succinate, and conjugated or esterized estrogens are available in various preparations Box 2. Systemic administration can be by the oral, transdermal, intranasal, or intramuscular route. For urogenital symptoms, estradiol is given as a vaginal tablet, ring, or cream; estriol is also given in these ways for this indication.
Estradiol can be given transdermally as a plaster or gel in dosages from 0. For the vaginal application of estradiol, there are vaginal tablets containing 0. The daily dose of estriol administered vaginally ranges from 0. This is why the usual doses vary depending on the route of administration. Drugs are very well absorbed when given vaginally. After the oral administration of 2 mg of estradiol, serum levels of ca.
It should be borne in mind that the vaginal administration of estrogens also gives rise to measurable serum concentrations. For example, when 0. Thus, vaginally administered estrogens can have systemic effects. Tibolone, a norethinodrel derivative with estrogenic, androgenic, and gestagenic properties, is also used to treat climacteric symptoms 1 , 2 , e1. Before any hormone therapy is started, the indication should be carefully considered; the patient should be evaluated with extensive history-taking and physical examination, including a gynecological examination.
Only in this way can the physician detect certain contraindications and health risks that might arise if HT were to be initiated Table. These risks may be independent of the duration of therapy and the time of its initiation in relation to the age of menopause see text; adapted from .
Many placebo-controlled, double-blind trials have shown that HT relieves vasomotor symptoms. Estrogens have been found to be effective, sometimes in combination with gestagens and tibolone. The reported side effects include breast tenderness, uterine bleeding, hemorrhage, arthralgia, emotional changes irritability, loss of motivation, depression, other , and, less commonly, nausea, vomiting, headache, weight changes, rash, and pruritus relative risk, 1. The risks of other important clinical endpoints are mentioned in other subsections of this review.
The efficacy of HT is rated as high in a position statement of the North American Menopause Society, published in and closely following the German S3 guideline in updated form. Estrogen therapy ET with or without the additional administration of gestagens is stated to be the most effective treatment for perimenopausal vasomotor symptoms.
The latter are the main indication for HT Many placebo-controlled, double-blind trials of HT in symptomatic women have clearly revealed an effect on vasomotor symptoms.
Only a very small number of randomized, placebo-controlled trials have addressed this issue, yielding inconsistent findings. It should be pointed out that the quality of life was not defined uniformly.
No improvement in the quality of life was found in the WHI study, yet smaller-scale placebo-controlled trials that were conducted over relatively short times did, in fact, reveal that HT improved the quality of life. The consensus paper of the North American Menopause Society takes the position that it is unclear whether HT improves the health-related quality of life of asymptomatic women A meta-analysis of 50 small-scale trials led to the conclusion that ET can partially or completely relieve urinary incontinence, particularly when an overactive bladder is the cause.
Meta-analyses have led to the conclusion that HT by any route of administration improves the signs and symptoms of vaginal atrophy 12 , e6. Low-dose, local ET is just as effective as systemic ET. If symptomatic vaginal atrophy is the only indication for treatment, local vaginal ET should be given.
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