What is the best treatment for menopause

Hormone Replacement Therapy - Menopausal hormones

With hormone replacement therapy (HRT), the hormone deficiency that occurs during menopause is artificially compensated for with medication. Hormone replacement therapy does not aim to exactly restore the previous hormone concentration in the body, but rather aims to specifically eliminate the symptoms and diseases of menopause caused by estrogen deficiency. Menopausal symptoms such as vasomotor symptoms such as hot flashes as well as sleep disorders, depressive moods, urological complaints and other complaints, which sometimes significantly impair the quality of life and performance of some women, can be effectively treated by hormone replacement therapy. The symptoms mentioned can be improved or, ideally, eliminated, provided that they appear for the first time or intensify during the menopause. (1)
 
Medical reasons (indications) for the use of hormone replacement therapy are currently the treatment of climacteric complaints such as hot flashes and tissue atrophy of the genital mucous membrane (atrophy) and the associated urogenital complaints. The prevention of diseases (e.g. osteoporosis, depression) is not a conventional medical indication for hormone replacement therapy. For the primary prevention of osteoporosis, hormone replacement therapy is only recommended if there is a high risk of bone fracture and intolerance or contraindications (contraindications) to other drugs approved for the prevention of osteoporosis. (1.2)
 
Before hormone replacement therapy is recommended by the gynecologist, a comprehensive examination, detailed questioning and consultation of the patient and possibly a determination of the hormone level by means of a blood test are essential. The doctor and patient will then weigh up the benefits and risks of the therapeutic options together. A therapy decision for the use of hormones is always made together with the patient - as with other treatments. Two principles are always observed in hormone replacement therapy: the lowest effective dose is used during the individually required treatment period. The intake should also be evaluated on a regular basis. In particular, it should be assessed whether the menopausal symptoms are regressing and whether there is satisfaction with the treatment results. During the course of treatment, regular annual check-ups should take place, including recording blood pressure, body weight and gynecological check-ups as well as breast examinations.

So far, no binding recommendation can be made about the duration of hormone replacement therapy. For example, one can consider completing hormone replacement therapy in the form of a slow withdrawal ("tapering off") of the medication after 3–5 years of use. Of course, you always have to discuss this with the doctor treating you. To end therapeutic measures, the dose can be slowly reduced over a period of about 2-3 months, for example. If symptoms recur, the hormone replacement therapy can be extended. (1.3)
 

Benefits and risks of hormone replacement therapy

The focus of the decision for or against treatment with hormones is always the personal level of suffering and the severity of the complaints, which are weighed against the individual risks. Ultimately, the therapy is designed according to the personal wishes of the patient, who can decide for or against hormone replacement treatment after thorough clarification.

What is certain is that vasomotor menopausal symptoms with the main symptom of hot flashes can be effectively treated with hormone replacement therapy. In addition, other complaints such as depressive mood, sleep disorders, performance and memory disorders, bone and joint complaints as well as urogenital complaints (skin and mucous membrane changes), which sometimes significantly impair the quality of life of women, can be alleviated. (1) On the other hand, as with almost all drug treatments, there are various risks that make a careful risk-benefit assessment necessary.

Various constellations have emerged in which hormone treatment has a clear benefit or should only be considered in exceptional cases. Therapy considerations are geared even more closely to the individual medical needs of women and risk factors and previous illnesses can be included in the treatment planning in a more defined manner. The different active ingredients and preparations can also be used in a more targeted manner. There are different estrogens and progestins with different risks.

For women with menopausal symptoms, well-founded information about the advantages and disadvantages of hormone replacement therapy is very important in order to be able to make a competent and self-determined decision in connection with the treatment of their menopausal symptoms.

When deciding on therapy, the focus has shifted to the age of the women and the time of their individual menopause. Ideally, replacement treatment begins with the onset of menopause, but no later than the age of 60 or less than 10 years after the onset of menopause. Furthermore, there should be no contraindications or increased risks, e.g. for cardiovascular diseases (cardiovascular diseases) or breast cancer (breast cancer). (4)
 
For women in the younger age groups, various preventive effects of hormone replacement therapy have been described, which, however, are not an indication for HRT in conventional medicine - but can be taken into account in individual cases: protective effect against colon cancer, risk reduction with regard to the development of diabetes mellitus II and myocardial infarction. (1)
   
In women from the age of 60 years, hormone replacement therapy should be started with a strict risk-benefit assessment, as the risk of cardiovascular diseases increases in predisposed women from this age. (1.3)

Adverse effects of hormone replacement therapy

An increased risk of breast cancer (breast cancer) cannot be ruled out with long-term use of hormone replacement therapy (longer than 3-5 years). A corresponding increase in risk was observed for the combination of estrogens with gestagens (medroxyprogesterone acetate, norethisterone acetate) after more than five years of treatment. (1) The treatment does not initially appear to trigger breast cancer, but rather to stimulate existing cancer cells to grow.

With estrogen-only therapy, the risk of endometrial cancer (cancer of the lining of the womb) increases after 2-3 years of use. The increased risk is reliably reduced by the additional administration of progestins. (5)

Hormone replacement therapy carries an increased risk of clogging of the bloodstream by the body's own substances (venous or arterial thromboembolism), at least if the patient is older or older. One speaks of a previous exposure if the woman has previously had a thrombosis, has had cases of thrombosis in the family, is overweight or had to stay in bed for longer periods (e.g. after a broken bone, surgery, etc.). An increase in risk was only observed with oral hormone replacement therapy. These risks can be reduced by an estrogen substitution through the skin (transdermal) at a dose below 50 micrograms. (1)

A comparison with other factors that increase your risk of heart disease or cancer can help you make a decision. Excessive obesity, regular alcohol consumption, lack of exercise and smoking increase the risk of breast cancer significantly more than hormone replacement treatment - this has also been made clear in the past. For the use of hormone replacement therapy, however, the principle applies that the lowest effective dose should be taken over the individually required period in order to minimize risks.

Active ingredients and dosage forms of hormone replacement therapy

A basic distinction is made between monotherapy, in which only estrogens are used, and combination therapy, in which a combination of estrogen and progestin is used. The use of estrogens with the aim of alleviating symptoms caused by hormone deficiency is called estrogen substitution. The selection of active ingredients, dosages and dosage forms depends on various factors. The administration of active substances through the mouth by swallowing is also called "oral", the absorption of active substances through the skin as "transdermal".
Tablets, plasters, creams and gels are available as dosage forms. For the local treatment of urogenital complaints only (e.g. vaginal dryness, urinary tract infections), estrogen-containing creams and ointments as well as vaginal tablets or ovules, pessaries and vaginal rings can be used.

The dosage of the hormones is based on the lowest dose with which the menopausal symptoms can be adequately treated.

So far, there are no clear recommendations for the use of herbal medicinal products (phyto-therapeutics) - also because there are no meaningful studies that clearly prove their effectiveness.

Adjusting the lifestyle during menopause

In old age, muscle mass decreases and the energy requirement also decreases. Women who do not adjust their eating habits accordingly can expect weight gain. Exercise and exercise can increase your energy requirements and prevent weight gain.

The calorie intake can also be reduced by eating a balanced whole food diet with little sugar, fat, sausage and white flour. A change in diet or lifestyle can also include abstaining from nicotine, alcohol, coffee, black tea or hot spices. (6)

Coping with hot flashes

Women who suffer from hot flashes can dress appropriately. Depending on the outside temperature, you can, for example, wear several thin layers of clothing on top of each other and, if necessary, flexibly store individual layers. Functional underwear can transport sweat away from the body better. In addition, women who sweat may find it helpful to have a change of clothes on hand. (6)
 
Even during the night's sleep in bed, you can react flexibly to hot flashes and sweats with two thin blankets instead of thick and functional underwear. It can also provide relief by fanning yourself with a fan during the flushes. (6)

The approach of hot flashes can also be suppressed if those affected run cold water over their wrists. (3.6)
 
Regular exercise and sport, as well as relaxation exercises and contrast showers can also help relieve the symptoms of hot flashes. Exercising and avoiding stress also helps with insomnia. (6)

Dealing with bladder weakness and dry mucous membranes

Bladder weakness can be counteracted by pelvic floor exercises - combined with plenty of fluid to avoid concentrated acidic urine. However, they should be built into the daily routine permanently. For women with a frequent urge to urinate, there is also specific bladder training that aims to increase the bladder capacity again. You can find detailed information on bladder training on the website of the Institute for Quality and Efficiency in Health Care (https://www.gesundheitsinformation.de/blasentraining.2289.de.html). (6)

In the case of dryness of the mucous membranes, in addition to the estrogens, care creams help against itching and sore feelings, while lubricants can protect against pain and irritation during sex. (6)
   
In order to support the skin, care should generally be taken to ensure that there is sufficient fluid intake. This is the prerequisite for the skin to be well hydrated and also to look firmer. It should be at least 1.5 to 2 liters per day, unless a heart or kidney disease speaks against it. (Tap) water, unsweetened juices or tea are best. In addition, it is advisable to ensure adequate protection against UV radiation.

Dealing with depressive moods

If they occur with the onset of menopause, immediate hormone replacement therapy can be effective. Psychotherapeutic support may be necessary in the case of pronounced psychological problems. Depression does not necessarily occur more frequently during menopause than in other phases of life. However, women who have already experienced depressive episodes are more susceptible at this stage of life. Other women can learn to adapt the demands they place on themselves to their resilience and to adapt their lives to their needs. (2,6) A depressive mood cannot be reliably prevented. But there is something you can do to reduce the risk and to feel more balanced and more comfortable. In addition to as much exercise as possible in nature, relaxation exercises help to relieve tension and stress and to improve your own body awareness and the awareness of your own needs. A healthy diet is also an important aspect, as is the perception of social contacts and exchanges with other people.
 

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  1. Mueck A. O., application recommendations for hormone substitution in climacteric and postmenopausal, gynecologist 56 (2015) No. 8
  2. www.krebsinformationsdienst.de/vorbeugung/risiken/hormon Ersatztherapie1.php
  3. Reuter M., Fassnacht M., Hormone Therapy through the Ages, Dtsch Med Wochenschr 2016; 141: 161-164
  4. Stuenkel C. A., Menopausal Hormone Therapy: Current Considerations, Endocrinol Metab Clin N Am 44 (2015) 565-585 dx.doi.org/10.1016/j.ecl.2015.05.006
  5. Brinton L.A., Felix A.S., Menopausal Hormone Therapy and Risk of Endometrial Cancer, J Steroid Biochem Mol Biol. 2014 Jul; 142: 83-89. www.ncbi.nlm.nih.gov/pmc/articles/PMC3775978/
  6. Camp C., Menopause, profamilia 2015

Author (s): äin-red

Technical support: Dr. Christian Albring

Last update: May 18, 2018