Population Care

Clearing the air on treatment for menopausal symptoms

Georgia Garvey , Contributing News Writer

Madelyn Butler, MD, remembers the day in 2002 when the public learned the results of the Women’s Health Initiative study, which confirmed that combined estrogen plus progestin increased the risk of incident breast cancer in postmenopausal women enrolled in the randomized controlled trial.

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“In my practice, my phone would not stop ringing and everyone was calling. They were worried about their hormone-replacement prescription,” said Dr. Butler, a member of the AMA Board of Trustees and an ob-gyn in Tampa, Florida.

The landmark study, published in JAMA®, presented a turning point in the treatment of post-menopausal and perimenopausal women, Dr. Butler explained during an episode of “AMA Update” in which she discussed hormone therapy and other treatments.

“What we had at the time told us that every woman in menopause, most every woman with the exception of a few with cancer risk, should be on hormone replacement,” Dr. Butler said.

She said that when the study showed an increased risk of breast cancer, cardiovascular disease and Alzheimer’s, it began a shift toward tailoring treatment for menopausal symptoms to the woman seeking relief.

“Now everything has changed to a more individualized approach,” Dr. Butler said, noting that, for most women, the symptoms of menopause are mild and manageable.

“Perimenopause and menopause can vary so much from woman to woman because 85% of us will have minimal symptoms,” she said.

In the remaining 15%, different categories of menopause can cause symptoms of varying types and suddenness.

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The treatment for a patient undergoing surgical menopause after the removal of her ovaries may not be the same as the treatment for a woman in drug-induced menopause who has been on chemotherapy for breast cancer, Dr. Butler noted.

“That woman may not be able to take estrogen. But there are certainly other things that we can do to treat symptoms that really affect her quality of life, like vaginal dryness,” she said. “If you have a patient that's dealing with cancer, she's had chemo and now she can't have intercourse with her partner, that is something that really affects relationships and quality of life, and just satisfaction with life in general.”

And the choices of medications to offer have expanded.

There are now estradiol gels, pellets and transdermal patches, proprietary herbal blends such as Relizen to target hot flashes and night sweats, as well as over-the-counter sleep aids for insomnia.

For patients in physiologic perimenopause who may have experienced a more gradual emergence of symptoms, Dr. Butler often starts with herbal or over-the-counter treatments, as opposed to prescription medication.

“The treatment of menopause is very tailored to the individual patient,” she added.

Learn more with this Feb. 7, 2023, JAMA review article on the management of menopausal symptoms.

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Some women also may not understand how long the transition of menopause lasts—about three to eight years. Others may not realize that their symptoms may not be from perimenopause but from stress due to career changes, caring for elderly parents or becoming an empty nester, all of which are common to women in that phase of life.

“Sometimes patients overlook their need for help, and they don't know how to differentiate what are symptoms of perimenopause and what are symptoms of the stresses that they're facing in their daily life,” she said.

In the coming years, Dr. Butler said she hopes to see more research on the topic, including on holistic treatments such as acupuncture. And she’d like to see a head-to-head evaluation of different absorption modes of hormonal therapy.

Overall, though, Dr. Butler looks forward to what the future will bring. She said life expectancy for women in the year 1900 was about 49 years old. Now, many women are living into their 90s—sometimes longer.

“We're living about half of our life in menopause,” Dr. Butler said. “So, I'm excited to know what the research is going to show in this last, most important part, I think, of our lives.”

AMA Update” covers health care topics affecting the lives of physicians and patients. Hear from physicians and experts on public health, advocacy issues, scope of practice and more—because who’s doing the talking matters. You can catch every episode by subscribing to the AMA’s YouTube channel or the audio-only podcast version, which also features educational presentations and in-depth discussions.