Consensus statement
Consensus statement for non-estrogen-based treatments for menopausal symptoms
Post Reproductive Health 2014, Vol. 20(2) 76–79 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2053369114536103 prh.sagepub.com
Jane Woyka1,2 and Nuttan Tanna3
Abstract Non-estrogen-based therapies can be used for the treatment of hot flushes, for symptoms of urogenital atrophy and for lack of sexual desire and/or fatigue not improved by estrogen treatments. Treatment choice should be based on upto-date information and targeted to individual women’s needs. Non-hormonal therapies are useful particularly for women with estrogen-dependent disease such as breast and endometrial cancers.
Keywords Breast cancer, menopause, non-hormonal therapies, sexual desire, urogenital atrophy
Introduction Non-hormonal and hormonal strategies will be discussed. Complementary or alternative therapies are covered in the consensus statement ‘Alternative Therapies’. Non-hormonal therapies are useful particularly for women with estrogen-dependent disease such as breast1–3 and endometrial cancers.
Hot flushes Hot flushes and night sweats are the most common menopausal symptoms, and there is evidence they may last for several years.4 Several non-estrogen agents have been used for symptom control although none are as effective as estrogen.5,6 The non-hormonal therapies that have been tested in randomised placebo-controlled trials and shown to be effective include paroxetine, fluoxetine, citalopram and escitalopram, venlafaxine and desvenlafaxine, and gabapentin and pregabalin.2,6 1. Selective serotonin reuptake inhibitors (SSRIs)/ licensed class antidepressants SSRIs such as paroxetine, fluoxetine, citalopram and escitalopram all have been studied for reduction in vasomotor symptoms. The SSRI with the best evidence is paroxetine7 with more recent studies assessing efficacy for citalopram and escitalopram.8–12 Some SSRIs are known to have a strong potency for inhibiting cytochrome P450 (CYP) 2D6, an enzyme that is important in the metabolism of
many drugs including tamoxifen.13 SSRIs such as paroxetine and fluoxetine are known to inhibit CYP2D6 and therefore should be avoided in patients who are concomitantly taking tamoxifen.2,13 Citalopram has weak inhibitory potency and can be taken with tamoxifen.13,14 Paroxetine is the SSRI with the best evidence for efficacy6,7 and is the SSRI for choice for patients not taking tamoxifen.15 Paroxetine is effective at a dose of 10 mg daily. Higher doses are not associated with improved control of flushes although the more usual dose of 20 mg may be used if an antidepressant effective is also desired.16 These SSRIs have been evaluated in short-duration trials for menopause symptom control. All SSRI s may have an adverse effect on libido. 2. Serotonin noradrenaline reuptake inhibitor/licensed class antidepressants Venlafaxine is used at doses of 37.5 mg to 150 mg daily on an off-licence basis. The 75 mg daily dose 1 GP Associate Specialist, The Northwick Park Menopause Clinical & Research Unit, North West London Hospitals NHS Trust, Middlesex, UK 2 GP Partner, The Harrow Health Care Centre, Clementine Churchill Hospital, Middlesex, UK 3 Pharmacist Consultant, Women’s Health & Older People, The Northwick Park Menopause Clinical & Research Unit, North West London Hospitals NHS Trust, Middlesex, UK
Corresponding author: Jane Woyka, The Northwick Park Menopause Clinical & Research Unit, North West London Hospitals NHS Trust, Watford Road, Harrow, Middlesex HA1 3UJ, UK. Email: [email protected]
Downloaded from min.sagepub.com at Freie Universitaet Berlin on June 28, 2015
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is generally well tolerated with moderate gastrointestinal or central nervous system symptoms affecting 10–20% of users.7,17,18 Patients should be counselled about the possible immediate side effect of nausea which may be reduced by using a longacting formulation as a once-daily dose with food. A long-acting formulation may also offer better control due to sustained levels. Venlafaxine should be taken in the morning as it may interfere with sleep. Venlafaxine has weak inhibitory potency for the CYP2D6 enzyme;13 so compared to SSRIs, it is a preferred treatment option for patients on tamoxifen. Venlafaxine may have an adverse effect on libido but to a lesser extent than with SSRIs. Desvenlafaxine has also been studied for control for hot flushes but is not available in the UK.19 3. Gamma amino butyric acid/licensed class antiepileptics Gabapentin has been studied in breast cancer patients taking tamoxifen although in short-duration 12-week trials.7,20 The dose is 900 mg daily, prescribed on an off-license basis, with an initial regime of 300 mg on day 1, 300 mg twice daily on day 2, then 300 mg three times daily from day 3. Clinical experience21 suggests that slower titration of increase in dose may help with improved patient compliance/concordance as many patients report drowsiness. If drowsiness during the day is a major presenting side effect, administration of the total dose at night could be tried. A meta-analysis from 2006 suggested that overall gabapentin has the best evidence for vasomotor symptom control but is not well tolerated with 50% of patients reporting at least one adverse event.7 Pregabalin decreases hot flushes and is reasonably well tolerated at a recommended dose of 75 mg twice daily. Pregabalin has not been tested in the breast cancer population. Its effects are roughly comparable to gabapentin and some of the newer antidepressants.3,22 4. Alpha adrenergic receptor agonist/licensed class antihypertensive and menopause symptom control Clonidine is the only non-hormonal drug with a licensed indication for control of hot flushes.23 It does help some patients with reduced hot flushes although the evidence base is contradictory.7,24 Clonidine 25 mcg is prescribed twice daily for two weeks, with dose increased to three times a day if needed. Side effects include difficulty sleeping in up to half of users. Caution with clonidine is advised due to its impact on blood pressure, and it may not be suitable for patients with generally low blood pressure. It should also not be stopped abruptly as this causes rebound hypertension in some patients.23 5. Progestogens/licensed class ‘hormones used in gynaecology’
Progestogens have been used on an unlicensed basis for menopause vasomotor symptom control. Norethisterone at a dose of 5 mg three times daily can improve flushes very significantly in many patients. The dose needed to achieve control of vasomotor symptoms may increase the risk of venous thromboembolism, and NICE 200925 states that progesterone should not be prescribed in breast cancer patients. In patients with progesterone receptor sensitivity, progestogens should be avoided. Progestogens can be considered for vasomotor symptom control in patients with non-hormonal sensitive tumours after a risk–benefit discussion.
Urogenital problems Vulvar and vaginal atrophy is an unremitting medical condition experienced by many postmenopausal women.26,27 Symptoms include dyspareunia (pain with intercourse), vaginal dryness and irritation and may affect sexual activities, relationships and activities of daily life. The standard effective treatment is vaginal estrogen therapy.27 However, in women who do not wish to use local estrogen therapy, vaginal moisturisers are an option that can provide long-term relief of vaginal dryness. These may contain a bioadhesive polycarbophil-based polymer which attaches to mucin and epithelial cells on the vaginal wall and retains water. ReplensMD is an example of a vaginal moisturiser available on prescription in the UK, and is used at least twice weekly. Patients often notice a shedding process shortly after starting treatment. A plethora of vaginal lubricants are also available. Lubricants usually consist of a combination of protectants and thickening agents in a water soluble base. Some moisturisers and lubricants can be prescribed, and others are available online or through health stores and pharmacies. A Swedish study on sexual dysfunction in women with breast cancer and on adjuvant endocrine therapy found that women who were on aromatase inhibitors had insufficient lubrication and dyspareunia, whereas tamoxifen-treated patients reported dyspareunia more frequently.28 These women would benefit from vaginal moisturisers and lubricants.
Lack of sexual desire Forty percent of postmenopausal women report loss of sexual desire.29–31 All women should be offered a holistic management plan. This should include options to help with relief of localised vaginal symptoms if present, referral for counselling if required, with assessment for need for systemic hormonal treatment based on an individualised risk/benefit evaluation.
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Psychosexual therapy has a proven success rate.30 Several studies have shown the benefit of testosterone therapy, mainly in surgical or postmenopausal women using estrogen.32–35 In the UK, the only licensed preparations for women are subcutaneous implants or pellets which are becoming difficult to source. Testosterone patches for hysterectomised women who are also taking estrogen replacement therapy are no longer available. Testim36 and testogel,37 licensed for male hypogonadism, are sometimes used off-licence for women. The advice given to women is that they should make the 5 g sachet of testogel or the 5 g tube of testim last seven days. As this poses a challenge for accurate dosing, many practitioners will not prescribe these regimens for women. Tibolone,38,39 a gonadomimetic with estrogenic, progestogenic and weak androgenic activity is licensed as a hormone replacement treatment for use in postmenopausal women with menopausal symptoms. Its androgenic activity may improve libido, energy levels and general wellbeing.30,31,39
Summary practice points . Non-hormonal options are available for reducing vasomotor symptoms in women who cannot take estrogen but are less effective. . Vaginal estrogen replacement therapy, vaginal lubricants and vaginal moisturisers are available and can help with local symptom control. . The testosterone transdermal patch system is no longer available as a licensed preparation for women. . Tibolone provides estrogenic and androgenic benefits for postmenopausal women.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
References 1. Rada G, Capurro D, Pantoja T, et al. Non-hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane Database Syst Rev 2010; 9: CD004923. 2. Lammerink EA, de Bock GH, Schro¨der CP, et al. The management of menopausal symptoms in breast cancer survivors: case-based approach. Maturitas 2012; 73: 265–268.
3. Sideras K and Loprinzi CL. Nonhormonal management of hot flashes for women on risk reduction therapy. J Natl Compr Canc Netw 2010; 8: 1171–1179. 4. Freeman G, Samuel M, Lin H, et al. Duration of menopausal hot flushes and associated risk factors. Obstet Gynecol 2011; 117: 1095–1104. 5. Sassarini J and Lumsden MA. Non-hormonal management of vasomotor symptoms. Climacteric 2013; 16(Suppl 1): 31–36. 6. Carroll DG and Kelley KW. Use of antidepressants for management of hot flashes. Pharmacotherapy 2009; 29: 1357–1374. 7. Nelson H, Vesco K, Haney E, et al. Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA 2006; 295: 2057–2071. 8. Suvanto-Luukkonen E, Koivunen R, Sundstrom H, et al. Citalopram and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomised, 9 month, placebo controlled, double blind study. Menopause 2005; 12: 18–26. 9. Kalay AE, Demir B, Haberal A, et al. Efficacy of citalopram on climacteric symptoms. Menopause 2007; 14: 223–229. 10. LaCroix AZ, Freeman EW, Larson J, et al. Effects of escitalopram on menopause-specific quality of life and pain in healthy menopausal women with hot flashes: a randomized controlled trial. Maturitas 2012; 73: 361–368. 11. Ensrud KE, Joffe H, Guthrie KA, et al. Effect of escitalopram on insomnia symptoms and subjective sleep quality in healthy perimenopausal and postmenopausal women with hot flashes: a randomized controlled trial. Menopause 2012; 19: 848–855. 12. Freeman EW, Guthrie KA, Caan B, et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA 2011; 305: 267–274. 13. Jin Y, Desta Z, Stearns V, et al. CYP2D6 genotype, antidepressant use, and tamoxifen metabolism during adjuvant breast cancer treatment. J Natl Cancer Inst 2005; 97: 30–39. 14. Lash TL, Cronin-Fenton D, Ahern TP, et al. Breast cancer recurrence risk related to concurrent use of SSRI antidepressants and tamoxifen. Acta Oncol 2010; 49: 305–312. 15. L’Espe´rance S, Frenette S, Dionne A, et al. Pharmacological and non-hormonal treatment of hot flashes in breast cancer survivors: CEPO review and recommendations. Support Care Cancer 2013; 21: 1461–1474. 16. Paroxetine 20 mg. Summary of product characteristics (last updated eMC: 24 August 2011), http:// www.medicines.org.uk/emc/medicine/23046/SPC/ Paroxetineþ20mgþTablets/ (2011, accessed 6 May 2014). 17. Loprinzi CL, Kugler JW, Sloan JA, et al. Venlafaxine in the management of hot flashes in survivors of breast cancer: a randomised, controlled trial. Lancet 2000; 356: 2059–2063. 18. Evams ML, Pritts E, Vittinghoff E, et al. Management of postmenopausal hot flushes with venlafaxine
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hydrochloride: a randomised, controlled trial. Obstet Gynecol 2005; 105: 161–166. Speroff L, Gass M, Constantine G, et al. Efficacy and tolerability of desvenlafaxine succinate treatment for menopausal vasomotor symptoms: a randomised controlled trail. Obstet Gynecol 2008; 111: 77–87. Pandya KJ, Morrow GR, Roscoe JA, et al. Gabapentin for hot flashes in 420 women with breast cancer: a double-blind placebo controlled trial. Lancet 2005; 366: 818–824. Pop A, Tanna N and Pitkin J. Breast cancer patient case study – prescribing of gabapentin for vasomotor symptom control and supporting patient compliance/concordance. Maturitas 2009; 63: S53. Loprinzi CL, Qin R, Balcueva EP, et al. Phase III, randomized, double-blind, placebo-controlled evaluation of pregabalin for alleviating hot flashes, N07C1. J Clin Oncol 2010; 28: 641–647. Clonidine 25 mcg. Summary of product characteristics (last updated eMC: 02 August 2012), http:// www.medicines.org.uk/emc/medicine/21711/SPC (2012, accessed 6 May 2014). Pandya KJ, Raubertas RF, Flynn PJ, et al. Oral clonidine in postmenopausal patients with breast cancer experiencing tamoxifen-induced hot flushes: a University of Rochester Cancer Center Community Clinical Oncology Program study. Ann Intern Med 2000; 132: 788–793. Early and locally advanced breast cancer. Diagnosis and treatment. NICE Clinical Guideline 80. Quick reference guide, www.nice.org.uk/nicemedia/pdf/CG80QuickRef Guide/pdf (2009, accessed 6 May 2014). Kingsberg SA, Wysocki S, Magnus L, et al. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med 2013; 10: 1790–1799. Sinha A and Ewies AA. Non-hormonal topical treatment of vulvovaginal atrophy: an up-to-date overview. Climacteric 2013; 16: 305–312. Baumgart J, Nilsson K, Evers AS, et al. Sexual dysfunction in women on adjuvant endocrine therapy after breast cancer. Menopause 2013; 20: 162–168.
29. Lindau ST, Schumm LP, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357: 762–774. 30. Tomlinson JM, Rees M and Mander T (eds). Sexual health and the menopause. London: RSM Press and British Menopause Society Publications, 2005. 31. Wylie KR. Sexuality and the menopause. J Br Men Soc 2006; 12: 149–152. 32. Davis SR, van der Mooren MJ, van Lunsen RH, et al. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomised, placebo controlled trail. Menopause 2006; 13: 387–396. 33. Braunstein GD, Sundwell DA, Katz M, et al. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomised, placebo controlled trial. Arch Intern Med 2005; 165: 1582–1589. 34. Simon J, Braunstein G, Nachtigall L, et al. Testosterone patch increases sexual activity and desire in surgically menopausal women with hypoactive sexual desire disorder. J Clin Endocrinol Metab 2005; 90: 5226–5233. 35. Shifren JL, Davis SR, Moreau M, et al. Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results from the INTIMATE NMI study. Menopause 2006; 13: 770–779. 36. Testim 50 mg gel. Summary of product characteristics (last updated eMC: 25 July 2012), http://www.medicines. org.uk/emc/medicine/22159/SPC/TestimþGel/ (2012, accessed 6 May 2014) 37. Testogel 50 mg gel. Summary of product characteristics (last updated eMC: 15 June 2007), http://www.medicines. org.uk/emc/medicine/12391 (2007, accessed 6 May 2014). 38. Livial 2.5 mg. Summary of product characteristics (last updated eMC: 18 November 2013), http://www. medicines.org.uk/emc/medicine/8552/SPC/ Livialþ2.5mgþtablets/ (2013, accessed 6 May 2014) 39. Tibolone 2.5 mgm tablets. Public assessment report, MHRA, http://www.mhra.gov.uk/home/groups/l-unit1/ documents/websiteresources/con2023754.pdf (2006, accessed 6 May 2014).
How To Cite Woyka J and Tanna N. Consensus statement for non-estrogen-based treatments for menopausal symptoms. Post Reproductive Health 2014; 20(2): 76–79.
Downloaded from min.sagepub.com at Freie Universitaet Berlin on June 28, 2015
Consensus statement for non-estrogen-based treatments for menopausal symptoms
Post Reproductive Health 2014, Vol. 20(2) 76–79 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2053369114536103 prh.sagepub.com
Jane Woyka1,2 and Nuttan Tanna3
Abstract Non-estrogen-based therapies can be used for the treatment of hot flushes, for symptoms of urogenital atrophy and for lack of sexual desire and/or fatigue not improved by estrogen treatments. Treatment choice should be based on upto-date information and targeted to individual women’s needs. Non-hormonal therapies are useful particularly for women with estrogen-dependent disease such as breast and endometrial cancers.
Keywords Breast cancer, menopause, non-hormonal therapies, sexual desire, urogenital atrophy
Introduction Non-hormonal and hormonal strategies will be discussed. Complementary or alternative therapies are covered in the consensus statement ‘Alternative Therapies’. Non-hormonal therapies are useful particularly for women with estrogen-dependent disease such as breast1–3 and endometrial cancers.
Hot flushes Hot flushes and night sweats are the most common menopausal symptoms, and there is evidence they may last for several years.4 Several non-estrogen agents have been used for symptom control although none are as effective as estrogen.5,6 The non-hormonal therapies that have been tested in randomised placebo-controlled trials and shown to be effective include paroxetine, fluoxetine, citalopram and escitalopram, venlafaxine and desvenlafaxine, and gabapentin and pregabalin.2,6 1. Selective serotonin reuptake inhibitors (SSRIs)/ licensed class antidepressants SSRIs such as paroxetine, fluoxetine, citalopram and escitalopram all have been studied for reduction in vasomotor symptoms. The SSRI with the best evidence is paroxetine7 with more recent studies assessing efficacy for citalopram and escitalopram.8–12 Some SSRIs are known to have a strong potency for inhibiting cytochrome P450 (CYP) 2D6, an enzyme that is important in the metabolism of
many drugs including tamoxifen.13 SSRIs such as paroxetine and fluoxetine are known to inhibit CYP2D6 and therefore should be avoided in patients who are concomitantly taking tamoxifen.2,13 Citalopram has weak inhibitory potency and can be taken with tamoxifen.13,14 Paroxetine is the SSRI with the best evidence for efficacy6,7 and is the SSRI for choice for patients not taking tamoxifen.15 Paroxetine is effective at a dose of 10 mg daily. Higher doses are not associated with improved control of flushes although the more usual dose of 20 mg may be used if an antidepressant effective is also desired.16 These SSRIs have been evaluated in short-duration trials for menopause symptom control. All SSRI s may have an adverse effect on libido. 2. Serotonin noradrenaline reuptake inhibitor/licensed class antidepressants Venlafaxine is used at doses of 37.5 mg to 150 mg daily on an off-licence basis. The 75 mg daily dose 1 GP Associate Specialist, The Northwick Park Menopause Clinical & Research Unit, North West London Hospitals NHS Trust, Middlesex, UK 2 GP Partner, The Harrow Health Care Centre, Clementine Churchill Hospital, Middlesex, UK 3 Pharmacist Consultant, Women’s Health & Older People, The Northwick Park Menopause Clinical & Research Unit, North West London Hospitals NHS Trust, Middlesex, UK
Corresponding author: Jane Woyka, The Northwick Park Menopause Clinical & Research Unit, North West London Hospitals NHS Trust, Watford Road, Harrow, Middlesex HA1 3UJ, UK. Email: [email protected]
Downloaded from min.sagepub.com at Freie Universitaet Berlin on June 28, 2015
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is generally well tolerated with moderate gastrointestinal or central nervous system symptoms affecting 10–20% of users.7,17,18 Patients should be counselled about the possible immediate side effect of nausea which may be reduced by using a longacting formulation as a once-daily dose with food. A long-acting formulation may also offer better control due to sustained levels. Venlafaxine should be taken in the morning as it may interfere with sleep. Venlafaxine has weak inhibitory potency for the CYP2D6 enzyme;13 so compared to SSRIs, it is a preferred treatment option for patients on tamoxifen. Venlafaxine may have an adverse effect on libido but to a lesser extent than with SSRIs. Desvenlafaxine has also been studied for control for hot flushes but is not available in the UK.19 3. Gamma amino butyric acid/licensed class antiepileptics Gabapentin has been studied in breast cancer patients taking tamoxifen although in short-duration 12-week trials.7,20 The dose is 900 mg daily, prescribed on an off-license basis, with an initial regime of 300 mg on day 1, 300 mg twice daily on day 2, then 300 mg three times daily from day 3. Clinical experience21 suggests that slower titration of increase in dose may help with improved patient compliance/concordance as many patients report drowsiness. If drowsiness during the day is a major presenting side effect, administration of the total dose at night could be tried. A meta-analysis from 2006 suggested that overall gabapentin has the best evidence for vasomotor symptom control but is not well tolerated with 50% of patients reporting at least one adverse event.7 Pregabalin decreases hot flushes and is reasonably well tolerated at a recommended dose of 75 mg twice daily. Pregabalin has not been tested in the breast cancer population. Its effects are roughly comparable to gabapentin and some of the newer antidepressants.3,22 4. Alpha adrenergic receptor agonist/licensed class antihypertensive and menopause symptom control Clonidine is the only non-hormonal drug with a licensed indication for control of hot flushes.23 It does help some patients with reduced hot flushes although the evidence base is contradictory.7,24 Clonidine 25 mcg is prescribed twice daily for two weeks, with dose increased to three times a day if needed. Side effects include difficulty sleeping in up to half of users. Caution with clonidine is advised due to its impact on blood pressure, and it may not be suitable for patients with generally low blood pressure. It should also not be stopped abruptly as this causes rebound hypertension in some patients.23 5. Progestogens/licensed class ‘hormones used in gynaecology’
Progestogens have been used on an unlicensed basis for menopause vasomotor symptom control. Norethisterone at a dose of 5 mg three times daily can improve flushes very significantly in many patients. The dose needed to achieve control of vasomotor symptoms may increase the risk of venous thromboembolism, and NICE 200925 states that progesterone should not be prescribed in breast cancer patients. In patients with progesterone receptor sensitivity, progestogens should be avoided. Progestogens can be considered for vasomotor symptom control in patients with non-hormonal sensitive tumours after a risk–benefit discussion.
Urogenital problems Vulvar and vaginal atrophy is an unremitting medical condition experienced by many postmenopausal women.26,27 Symptoms include dyspareunia (pain with intercourse), vaginal dryness and irritation and may affect sexual activities, relationships and activities of daily life. The standard effective treatment is vaginal estrogen therapy.27 However, in women who do not wish to use local estrogen therapy, vaginal moisturisers are an option that can provide long-term relief of vaginal dryness. These may contain a bioadhesive polycarbophil-based polymer which attaches to mucin and epithelial cells on the vaginal wall and retains water. ReplensMD is an example of a vaginal moisturiser available on prescription in the UK, and is used at least twice weekly. Patients often notice a shedding process shortly after starting treatment. A plethora of vaginal lubricants are also available. Lubricants usually consist of a combination of protectants and thickening agents in a water soluble base. Some moisturisers and lubricants can be prescribed, and others are available online or through health stores and pharmacies. A Swedish study on sexual dysfunction in women with breast cancer and on adjuvant endocrine therapy found that women who were on aromatase inhibitors had insufficient lubrication and dyspareunia, whereas tamoxifen-treated patients reported dyspareunia more frequently.28 These women would benefit from vaginal moisturisers and lubricants.
Lack of sexual desire Forty percent of postmenopausal women report loss of sexual desire.29–31 All women should be offered a holistic management plan. This should include options to help with relief of localised vaginal symptoms if present, referral for counselling if required, with assessment for need for systemic hormonal treatment based on an individualised risk/benefit evaluation.
Downloaded from min.sagepub.com at Freie Universitaet Berlin on June 28, 2015
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Psychosexual therapy has a proven success rate.30 Several studies have shown the benefit of testosterone therapy, mainly in surgical or postmenopausal women using estrogen.32–35 In the UK, the only licensed preparations for women are subcutaneous implants or pellets which are becoming difficult to source. Testosterone patches for hysterectomised women who are also taking estrogen replacement therapy are no longer available. Testim36 and testogel,37 licensed for male hypogonadism, are sometimes used off-licence for women. The advice given to women is that they should make the 5 g sachet of testogel or the 5 g tube of testim last seven days. As this poses a challenge for accurate dosing, many practitioners will not prescribe these regimens for women. Tibolone,38,39 a gonadomimetic with estrogenic, progestogenic and weak androgenic activity is licensed as a hormone replacement treatment for use in postmenopausal women with menopausal symptoms. Its androgenic activity may improve libido, energy levels and general wellbeing.30,31,39
Summary practice points . Non-hormonal options are available for reducing vasomotor symptoms in women who cannot take estrogen but are less effective. . Vaginal estrogen replacement therapy, vaginal lubricants and vaginal moisturisers are available and can help with local symptom control. . The testosterone transdermal patch system is no longer available as a licensed preparation for women. . Tibolone provides estrogenic and androgenic benefits for postmenopausal women.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
References 1. Rada G, Capurro D, Pantoja T, et al. Non-hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane Database Syst Rev 2010; 9: CD004923. 2. Lammerink EA, de Bock GH, Schro¨der CP, et al. The management of menopausal symptoms in breast cancer survivors: case-based approach. Maturitas 2012; 73: 265–268.
3. Sideras K and Loprinzi CL. Nonhormonal management of hot flashes for women on risk reduction therapy. J Natl Compr Canc Netw 2010; 8: 1171–1179. 4. Freeman G, Samuel M, Lin H, et al. Duration of menopausal hot flushes and associated risk factors. Obstet Gynecol 2011; 117: 1095–1104. 5. Sassarini J and Lumsden MA. Non-hormonal management of vasomotor symptoms. Climacteric 2013; 16(Suppl 1): 31–36. 6. Carroll DG and Kelley KW. Use of antidepressants for management of hot flashes. Pharmacotherapy 2009; 29: 1357–1374. 7. Nelson H, Vesco K, Haney E, et al. Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA 2006; 295: 2057–2071. 8. Suvanto-Luukkonen E, Koivunen R, Sundstrom H, et al. Citalopram and fluoxetine in the treatment of postmenopausal symptoms: a prospective, randomised, 9 month, placebo controlled, double blind study. Menopause 2005; 12: 18–26. 9. Kalay AE, Demir B, Haberal A, et al. Efficacy of citalopram on climacteric symptoms. Menopause 2007; 14: 223–229. 10. LaCroix AZ, Freeman EW, Larson J, et al. Effects of escitalopram on menopause-specific quality of life and pain in healthy menopausal women with hot flashes: a randomized controlled trial. Maturitas 2012; 73: 361–368. 11. Ensrud KE, Joffe H, Guthrie KA, et al. Effect of escitalopram on insomnia symptoms and subjective sleep quality in healthy perimenopausal and postmenopausal women with hot flashes: a randomized controlled trial. Menopause 2012; 19: 848–855. 12. Freeman EW, Guthrie KA, Caan B, et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: a randomized controlled trial. JAMA 2011; 305: 267–274. 13. Jin Y, Desta Z, Stearns V, et al. CYP2D6 genotype, antidepressant use, and tamoxifen metabolism during adjuvant breast cancer treatment. J Natl Cancer Inst 2005; 97: 30–39. 14. Lash TL, Cronin-Fenton D, Ahern TP, et al. Breast cancer recurrence risk related to concurrent use of SSRI antidepressants and tamoxifen. Acta Oncol 2010; 49: 305–312. 15. L’Espe´rance S, Frenette S, Dionne A, et al. Pharmacological and non-hormonal treatment of hot flashes in breast cancer survivors: CEPO review and recommendations. Support Care Cancer 2013; 21: 1461–1474. 16. Paroxetine 20 mg. Summary of product characteristics (last updated eMC: 24 August 2011), http:// www.medicines.org.uk/emc/medicine/23046/SPC/ Paroxetineþ20mgþTablets/ (2011, accessed 6 May 2014). 17. Loprinzi CL, Kugler JW, Sloan JA, et al. Venlafaxine in the management of hot flashes in survivors of breast cancer: a randomised, controlled trial. Lancet 2000; 356: 2059–2063. 18. Evams ML, Pritts E, Vittinghoff E, et al. Management of postmenopausal hot flushes with venlafaxine
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