Menopause Symptoms? Learn About Your Treatment Options

Transcript:

Jamie Forward: It sounds like perimenopause is the phase where the most sort of troublesome symptoms occur. So, Dr. Ali, can you just give us an overview of the treatment options available?

Dr. Nina Ali: Yes. So, I would agree. Perimenopause is, I always tell my patients this too, this is the harder part for us to navigate and manage because it is so different for each person, the pattern is by definition unpredictable. And based on what priorities that particular patient has, you know, we kind of look at what are we going to target as far as management? And so, we do have to consider contraception for women who are still having periods, so that is an important piece as well that we don’t want to forget about.

And oftentimes, our contraceptives are able to both prevent pregnancy and also just sort of even out those fluctuations that are going to be happening, that we know are happening in perimenopause where you might have ovulation on top of ovulation which can really kind of make all sorts of symptoms worse including bleeding patterns and migraine headaches and mood and all of it. So, for women who get relief of both sides of things as far as bleeding pattern and the symptoms that go along with that through a low dose contraceptive, that is actually a great option.

It’s not for everybody, there are plenty of people who come in and see me and say, “I don’t want anything to do with contraception or birth control pills anymore,” or “I already had a tubal ligation, and I don’t need that.” But that’s one thing to keep in mind as kind of a simple and easily accessible way to manage perimenopause. Of course, we have all of our options of menopause formulations of hormone therapy, different forms of estrogens, different forms of progesterones.

And sometimes we’re bridging, we’re kind of using some contraceptive with maybe a transdermal estrogen patch. For example, the Mirena IUD does a great job of managing the heavy periods of perimenopause and providing uterine protection, and we can also give a different form of estrogen that may not be a contraceptive with that. So, there are lots of ways to be fun and creative, basically, is one of the things about perimenopause. And then there are, of course, nonhormonal options as well.

So, if most of the symptoms aren’t necessarily – are more kind of on the mood side of things, there may be ways that don’t involve hormones that we can really help kind of navigate through those symptoms as well. Or for women who cannot or do not want to take hormone therapy, there are prescription and nonprescription nonhormonal options. So, there’s quite wide a gamut of things that we get to talk about.

Jamie Forward: Yeah. And, Dr. Piasta, what would you add to that? I’ve heard about SSRIs, for example, being good for hot flashes. Is there anything you have to add as far as treatment options go?

Dr. Jackie Piasta: Yeah. Yeah. Well, I think in menopause and particularly in perimenopause, we get ourselves in a little bit of a mess because we have so many options to choose from. You know, how many times have you gone in for a blood pressure check and said you had high blood pressure and belabored over your options to treat your high blood pressure? So, this is a difficult conversation, and it sort of bleeds into a little bit of the why I’ve been dismissed and why maybe it’s hard to find somebody, because options are very nuanced. Dr. Ali was talking about before, certain contraindications.

So, we do have some individuals that maybe are not the best candidates for hormone therapy. I would be remiss if I didn’t say that we do have to recognize that hormone therapy is the gold standard across the board for menopause treatment. It can get a little messy, and we do have to be creative in a perimenopause space, but it’s the gold standard for the vast majority of women in menopause, particularly if it’s started early.

But there are wonderful nonhormonals. SSRIs have been used, we have one that is FDA-approved and that’s paroxetine (Paxil), and then the rest are used in a way that we call off-label. The most effective tends to be venlafaxine (Effexor XR), which tends to kind of be the next-preferred. SSRIs can be, and SNRIs can be great for some people, particularly those that struggle with their mood during this time. We also have a newer class of nonhormonals called our NKT therapies. And those therapies work on this set of neurons in our hypothalamus, which is the central part of our brain that regulates our thermostat, essentially.

And they’re these little neurons called kisspeptin, neurokinin, and dynorphin, not to get into the weeds too much, but they literally regulate our temperature, and they kind of play this little piggyback with estrogen.

So, those therapies can be really impactful. And the newest one, elinzanetant (Lynkuet) actually has shown pretty good data for sleep as well because it hits on a different substance in the brain that’s implicated in our sleep cycle as well. So, we have SSRIs, we have these NKT therapies, we also have gabapentin (Neurontin) and – oh, gosh. I can’t think of the trade name for it, but the branded name would be Lyrica, which sometimes we can use for different symptoms. And then we have oxybutynin (Ditropan), which is actually an old-school bladder medication which is on the list of medications for nonhormonals as well. And then there is some data to support certain complementary alternative therapies like Chinese medicine and cognitive behavioral therapy and certain forms of black cohosh and soy products.

But again, it’s why you have to individualize care. It’s why I always ask patients, “What are your goals, and what do you hope to get out of this visit? And in a perfect world, what would your treatment plan look like?”

Jamie Forward: Sure. And it sounds like this is kind of a moving target, right? As you guys have been discussing, it sounds like you’re going to have to keep having conversations like this with your doctor as you move through the various phases.