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Published on November 01, 2018

Behavior Modifications, HRT Help Women Manage Menopause

Most women in the U.S. begin menopause between the ages of 40-58, with an average of 51. Depleting estrogen levels leave women with a range of potentially life-disrupting symptoms and health risks, including genitourinary syndrome, hot flashes, mood changes, night sweats and sleep disturbance.

Yet, women oftentimes do not seek treatment. According to an American Association of Retired Persons 2018 survey of more than 400 women between the ages of 50-59, 42% reported they had never discussed menopause with a health provider. The survey also showed that only one
in five women received a referral to a menopause specialist.

A study published in the Feb. 18, 2016, issue of Post Reproductive Health looked at the attitudes and behaviors regarding treatment in women 45 years and older in France, Germany, Italy, Spain and the United Kingdom. Of the 3,890 peri- to postmenopausal women who completed the internet survey, 67% experienced symptoms, but 54% sought medical input or some treatment.


James E. Riojas, MD, FACOG, a gynecologist with Meritas Health Obstetrics & Gynecology, begins treating menopause symptoms with behavior modifications.

Behavior Modifications

Dr. Riojas begins by asking patients to try behavior modifications, which help relieve the symptoms of menopause:

  • Drink cool liquids
  • Keep a fan at their work desk and bedside
  • Limit alcohol and caffeine intake
  • Lose weight
  • Lower ambient temperatures
  • Stop smoking
  • Use a frozen gel pack with pillow at night
  • Wear layered, breathable clothing

If these efforts aren’t successful, he discusses two hormone replacement therapy options:

  1. Estrogen alone
  2. Estrogen and progesterone

HRT can relieve genitourinary syndrome, hot flashes, mood and sleep disturbances, and night sweats associated with menopause. “We try to reserve HRT for women with severe symptoms,” Dr. Riojas said. "We know HRT is generally safe and the most efficient treatment for menopausal symptoms. As one can expect with any kind of treatment, there are potential risks. We reserve the HRT option for women with life-altering symptoms.”

He noted that when estrogens were first prescribed for menopausal symptoms, women with a uterus who were given estrogen alone showed an increased risk for uterine cancer. Adding progesterone negated the risk of uterine cancer. “A woman with a uterus who is prescribed estrogen should also be prescribed progesterone,” Dr. Riojas said. “A woman who has had a hysterectomy can take estrogen alone.”

Estrogen forms include creams, lotions, patches, pills and vaginal rings. “Overall, we try to do something dermally versus pill form because it potentially has less cardiovascular risk,” he said.

Dr. Riojas cautioned that estrogen therapy is not indicated for women with a history of breast cancer, endometrial cancer, heart disease or unexplained abnormal vaginal bleeding, or with active liver disease.

Women's Health Initiative

The largest HRT investigation, the Women’s Health Initiative, launched in 1993. Conducted through 2010, it involved more than 161,000 women ages 50-79 at 40 clinical centers. Investigators studied three groups:

  1. Women who had a hysterectomy and took estrogen only
  2. Women with a uterus who took estrogen in combination with progesterone
  3. Women who took a placebo

“A number of adverse outcomes occurred, including breast cancer, deep vein thrombosis and stroke, in the study group using estrogen and progesterone, and the study was terminated,” Dr. Riojas said. “When the initial results were released, we saw a dramatic decrease in the amount of providers prescribing HRT and individuals requesting HRT.”

As more data became available during the second-half observational portion, physicians gained a better understanding of the effects of HRT. “The study wasn’t perfect,” Dr. Riojas said. “They took all comers, including people with active heart disease. Only 3% were at the average 50-51 age of menopause, so they had some individuals who received therapy whom we would consider contraindicated today. Our current understanding of the relative risk of HRT, based on the study arms, includes an increased risk of breast cancer, heart attack and stroke, but not in all groups.”

WHI Results

Estrogen-only Group

  • Slight increased risk for blood clots in lungs and legs and for stroke
  • Increased heart attack risk, but not in individuals fewer than 10 years from menopause, or ages 50-59
  • No evidence of increased risk of breast cancer in users after sever years or less
  • Fewer fractures

Combined Estrogen and Progesterone Group

  • Increased risk of breast cancer, heart attack, leg and lung blood clots, and stroke
  • Reduced risk of colorectal cancer
  • Fewer fractures

Bioidentical HRT

Manufactured or compounded in a local pharmacy, bioidentical hormones contain combinations of medications that can include multiple types of estrogen, progesterone and testosterone.

“One of the potential issues with bioidentical hormones is that the quality is not regulated to the same extent as with pharmaceutical products, so there is a potential that the dose could vary batch to batch,” Dr. Riojas explained.

Nonhormonal Treatments

Other treatment options include the only nonhormonal option for hot flashes in the U.S., Brisdelle®, which contains paroxetine.

“Brisdelle has been shown to modestly decrease the incidence of hot flashes, but it occasionally comes with side effects, including dizziness, fatigue and nausea,” Dr. Riojas said. “The important thing to remember about Brisdelle is it can inhibit tamoxifen’s action, so it should not be used in individuals with a history of breast cancer who are under treatment with tamoxifen.”

James E. Riojas, MD, FACOG

James Riojas, MDDr. Riojas earned his medical degree from the University of Missouri-Kansas City. He was an OB-GYN resident at Truman Medical Center. After providing gynecological and obstetrical care for more 27 years, Dr. Riojas has since focused his medical practice on gynecology.