Executive Summary
New research indicates that frequent vasomotor symptoms associated with menopause could last more than seven years for many women.
• If women are at the beginning of menopause, they might still be fertile. Low-dose combined oral contraceptives might offer pregnancy protection while tempering hot flashes and night sweats.
• Nonhormonal prescription treatments for managing vasomotor symptoms include use of selective serotonin-reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Nonprescription remedies include soy, isoflavone supplements, black cohosh, vitamin E, and yoga.
New research indicates that frequent vasomotor symptoms (VMSs) associated with menopause could last more than seven years for many women.1
The duration of vasomotor symptoms is an important question for women in general and the clinicians who treat them, says Nancy Avis, PhD, professor of public health sciences/social sciences at Wake Forest Baptist Medical Center in Winston-Salem, NC.
“Women want to know how long they can expect their hot flashes to last and whether it is unusual for them to last a long time,” remarks Avis, who served as lead author of the current paper. “Up to now, we have lacked good longitudinal data on this issue because it requires a long period of follow-up of women going through the menopausal transition; thus, clinicians have not been able to provide women with very good information.”
The Study of Women’s Health Across the Nation (SWAN), a multiracial/multiethnic observational study of women entering menopause, has been following women since 1996 and provides an ideal study in which to address this question, says Avis. She and her coauthors analyzed data from 1,449 women with frequent vasomotor symptoms (defined as six or more affected days in the previous two weeks). The research team is continuing to follow women in the SWAN study and might have even more information in a few years, Avis notes.
To conduct the current analysis, researchers evaluated women at a median of 13 visits during the study. Two primary outcomes were established: total VMS duration, which measured the years elapsed between the first and last report of frequent vasomotor symptoms, and post-final menstrual period, the number of years that frequent symptoms persisted after the final period. Cessation of vasomotor symptoms was defined as two consecutive visits without hormone replacement therapy or experiencing symptoms. Researchers also sought to identify risk factors for the two measures.
Analysis indicates the median total duration of vasomotor symptoms at 7.4 years. Among 881 women who were aware of their final menstrual period, the median post-final menstrual period persistence was 4.5 years.1
Timing of menopause emerged as an important factor in the duration of vasomotor symptoms, researchers report. The longest total vasomotor duration (median, more than 11.8 years) and post-final menstrual period persistence (median, 9.4 years) occurred among women who were premenopausal or early perimenopausal when they first experienced frequent vasomotor symptoms. Women who were postmenopausal when symptoms began had the shortest total symptom duration (median, 3.4 years). Black women experienced the longest total symptom duration (median, 10.1 years); Japanese and Chinese women reported the shortest symptom duration (median, 4.8 years and 5.4 years, respectively). The median total symptom durations were 6.5 years for non-Hispanic white women and 8.9 years for Hispanic women.1
Longer symptom duration was associated with younger age, lower educational level, history of smoking, greater perceived stress, greater sensitivity to symptoms, and depression and anxiety at the time of the first report of symptoms, researchers report. Shorter symptom duration was observed among women with partners, higher educational level, less financial pressure, and greater social support.1
If women are at the beginning of menopause, they might still be fertile, notes a commentary that accompanies the current paper.2 If these women experience frequent vasomotor symptoms, low-dose combined oral contraceptives might protect them from pregnancy while tempering hot flashes and night sweats, authors note.
With a longer timeframe for menopause, some women might look to nonhormonal treatments for managing vasomotor symptoms. The selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors paroxetine, escitalopram, venlafaxine, and desvenlafaxine have been shown to be more effective than placebo for hot flashes.3 Paroxetine 7.5 mg (Brisdelle, Noven Therapeutics, Miami) is the only SSRI approved by the Food and Drug Administration for this indication.3
Nonprescription remedies such as soy, isoflavone supplements, black cohosh, vitamin E, and omega-3 fatty acids are generally low risk but with efficacy generally similar to placebo, notes a 2014 clinical guidance issued by the North American Menopause Society (NAMS).3
Menopausal hormone therapy is the most effective treatment for vasomotor symptoms, notes the Society’s guidance. Options include systemic estrogen, estrogen-progestogen, estrogen-bazedoxifene, progestogen alone, or combined oral contraceptives in women requiring contraception.3 Duavee, marketed by Wyeth Pharmaceuticals, Philadelphia, a combination of the selective estrogen receptor modulator bazedoxifene and conjugated estrogen, is Food and Drug Administration-approved for the treatment of hot flashes.
According to the Society guidance, custom-compounded bioidentical hormones aren’t recommended because of lack of regulation, rigorous safety and efficacy testing, batch standardization, and purity measures.3 Many women use compounded bioidentical hormones, according to a recent analysis.4 Of the 57 to 75 million prescriptions for menopausal hormone therapies filled each year, 36 million prescriptions are written for Food and Drug Administration-approved hormone therapy. The remaining 28 to 39 million prescriptions are likely for compounded hormones, the analysis indicates.4
If you think hot flashes taper off as a woman reaches age 52, the year generally considered as the time of natural menopause, think again. Some 40% of women ages 60 to 65 still have hot flashes, according to a just-published study.5
While these hot flashes are occasional and mild for many women, for some such symptoms remain troublesome, data indicate. Women bothered by these symptoms often are not getting treatment, even though treatments are available, researchers report.5
Most guidelines recommend against using systemic hormones for women more than 10 years after menopause or after age 60 and to use them only for a limited time ideally 3-5 years in the case of combined estrogen/progestogen therapy. This recommendation is a change from the prescribing habits of the 1990s, when there was widespread use of hormone therapy for women in all phases of menopause, says Margery Gass, MD, NAMS executive director. Findings from the Women’s Health Initiative study changed such prescribing habits, with clinicians advised to prescribe only for symptoms and for a limited time.
Estrogen therapy alone has fewer risks than the combined therapy, but only women who have had a hysterectomy should use estrogen alone. It appears that estrogen alone can be used safely for a longer time, says Gass. Because later analyses of data indicated that older women had more side effects from hormonal therapy, the conclusion was that women should use hormone therapy in their early post-menopausal years when they are most symptomatic, then discontinue as soon as symptom relief is reached, notes Gass.
“Women need to know that they do still have options to treat their hot flashes and sexual symptoms, even if they are older or cannot or do not wish to use hormone therapy,” says Gass. “NAMS encourages all women bothered by their menopause symptoms to seek the help they need and not to give up.”
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Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med 2015; doi: 10.1001/jamainternmed.2014.8063.
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Richard-Davis G, Manson JE. Vasomotor symptom duration in midlife women — Research overturns dogma. JAMA Intern Med 2015; doi: 10.1001/jamainternmed.2014.8099.
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Shifren JL, Gass ML; NAMS Recommendations for Clinical Care of Midlife Women Working Group. The North American Menopause Society recommendations for clinical care of midlife women. Menopause 2014; 21(10):1038-1062.
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Pinkerton JV, Santoro N. Compounded bioidentical hormone therapy: Identifying use trends and knowledge gaps among US women. Menopause 2015; doi:10.1097/GME.0000000000000420.
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Gartoulla P, Worsley R, Bell RJ, et al. Moderate to severe vasomotor and sexual symptoms remain problematic for women aged 60 to 65 years. Menopause 2015; doi:10.1097/GME.0000000000000383.
