The American College of Obstetricians and Gynecologists has updated its Practice Bulletin for treating vasomotor symptoms of menopause ("hot flushes") and vaginal atrophy.
The updated bulletin, which replaces the June 2001 version, was published in the January 2014 issue of Obstetrics & Gynecology.
Hot flushes affect from 50% to 82% of US women who experience natural menopause, and 10% to 40% report vaginal atrophy. Of those who have hot flushes, 87% suffer daily and 33% have 10 or more episodes daily. Median duration of vasomotor symptoms is from 4 to 10.2 years.
Emphasis is placed on the importance of understanding the risks and benefits of different therapies and of individualizing therapy.
The recommendations are listed in 3 tiers:
- Level A ("good or consistent scientific evidence"):
- Systemic HT, with just estrogen or estrogen plus progestin, is the most effective approach for treating vasomotor symptoms.
- Low-dose and ultra-low systemic doses of estrogen have a more favorable adverse effect profile than standard doses.
- Healthcare providers should individualize care and use the lowest effective dose for the shortest duration.
- Thromboembolic disease and breast cancer are risks for combined systemic HT.
- Selective serotonin reuptake inhibitors, selective serotonin and norepinephrine reuptake inhibitors, clonidine, and gabapentin relieve vasomotor symptoms and are alternatives to HT.
- Local estrogen therapy is advised for isolated atrophic vaginal symptoms.
- The only nonhormonal therapy approved to treat vasomotor symptoms (in US) is paroxetine, and to treat dyspareunia is ospemifene.
- Level B conclusions ("limited or inconsistent scientific evidence"):
- Data do not support use of progestin alone, testosterone, compounded bioidentical hormones, phytoestrogens, herbal supplements, and lifestyle modifications.
- "Common sense lifestyle solutions" are layering clothing, lowering room temperature, and consuming cool drinks.
- Nonestrogen water-based or silicone-based lubricants and moisturizers may alleviate pain.
- Level C recommendation ("based primarily on consensus and expert opinion"):
- Individualize the decision to continue HT.
Obstet Gynecol. 2014;123:202-216.