A large and important clinical study, the WHI (Woman's Health Initiative, 2002) showed that estrogen-progesterone combination pills (hormone replacement therapy) significantly reduced hot flashes and vaginal dryness in postmenopausal women. However, this treatment increased the risk of blood clots, stroke, and breast cancer. Whether or not they also increase the risk of heart attack remains controversial.

The WHI study followed 16,000 women for an average of 5.2 years - half of the women took hormone pills; the other half took a "placebo" (fake treatment). For every 1,000 women enrolled in the study:

• Breast cancer developed in 3.8 of the women taking hormones versus 3.0 women on placebo
• Stroke developed in 2.9 of the women taking hormones versus 2.1 on placebo
• Blood clots developed in 3.4 of the women taking hormones versus 1.6 women on placebo. Women who took estrogen only rather than an estrogen-progestin combination had a slightly lower rate of breast cancer.

• Combination estrogen plus progestin pills - Premphase, Prempro, Ortho-Prefest, FemHRT, Activilla, etc;
• Estrogen pills (for either estrogen only or to combine with progestin - Premarin, Estratab, Cenestrin, Menest, Estinyl, Estrace, Ogen, Ortho-Est, etc;
• Progestin pills - Provera, Aygestin, Cycrin, Prometrium, Norlutate, etc.

Most studies on hormone replacement therapy have evaluated estrogen and progestin administered as pills. Both estrogen and progestin can be given with a skin patch, as well as orally. The difference is that hormones delivered through the patch go directly into the bloodstream, whereas those taken as a pill pass from the stomach through the liver and are chemically changed before entering the bloodstream. No one knows if this alteration has any effect on the risks, effectiveness, or side effects that might be related to patch administration.

There is some evidence to suggest that patches are effective for menopause symptoms but there is no information about the long-term effects of hormones delivered this way. Because of this, experts tend to recommend that patches be viewed as having the same potential risks that hormone pills do.

Patches that contain estrogen include: Climara, Esclim, Vivelle, etc; those containing both estrogen and progestin include: CombiPatch, etc. Patches can cause skin irritation in some women.

Since hot flashes tend to go away with time, lifestyle changes are a first choice treatment, especially for women with mild to moderate symptoms. Examples include wearing layers of easily removable clothing, using cold water, fans or icepacks during hot flashes, breathwork and relaxation training, and regular exercise.

There is some evidence that smoking, excessive body weight, and stress may increase the frequency and intensity of hot flashes.

The effectiveness of any of these measures are uncertain, but they are recommended in the North American Menopause Society (NAMS) guidelines since they do not cause harmful side effects, and menopausal symptoms (including hot flashes) usually improve with time in most women anyway.

Although good studies have found that progestins reduce hot flashes by at least 75%, they need to be given in very high doses (20-200 mg daily) when prescribed alone rather than in combination with estrogen. Such doses may cause a number of unpleasant side effects including: weight gain, bloating, mood changes, and irregular vaginal bleeding. Progesterone cream was not found to be effective in decreasing hot flashes.

Antidepressants often take 4 to 8 weeks to work for depression, but the effect on hot flashes is much quicker. One week of treatment can be enough to see whether or not these medications are going to work.

The North American Menopause Society (NAMS) guidelines recommend antidepressants for patients who cannot or should not take hormones.

Sexual problems are a common side effect.

The North American Menopause Society (NAMS) guidelines recommend gabapentin (Neurontin) as an alternative to hormone therapy for women who cannot take hormones. A newer similar drug, pregabalin (Lyrica) can also be used. They both should be taken at bedtime, since they can cause dizziness.

The dose may have to be gradually increased to be effective.

Soy foods contain an estrogen/female hormone-like substance called "phytoestrogen" and have been used as home remedies for menopause symptoms. There is some evidence that soy-containg foods might improve menopause symptoms, but the evidence is mixed. Some studies (mostly from Germany and using a German preparation of the product) showed some promising effects.

Isoflavones are one of the active chemicals in soy and are sometimes taken as supplements (40 to 80 mg/day) in place of dietary soy. Soy from foods, however, contains additional ingredients and it is not clear if supplements have the same effects as the foods. For this reason, guidelines recommend soy foods over the isoflavone supplements even though this approach is less convenient.

The North American Menopause Society (NAMS) guidelines consider soy-containing products/foods to be not harmful and suggest that they can be tried, except for certain women (who should also not receive supplemental female hormones/estrogen) including women who have a personal or strong family history of:

• breast, uterine, or ovarian cancer;
• blood clots;
• endometriosis;
• uterine fibroids.

Black cohosh (Actaea racemosa, Cimicifuga racemosa) is an herbal preparation that has been used over the years to treat arthritis and muscle pain, and more recently in the U.S. for symptoms of menopause including hot flashes and vaginal dryness. It has been used for menopausal symptoms in Europe for a long time.

Studies are mixed about whether or not this herb is effective. Most of the studies performed are small and of poor quality. One study funded by the NIH's NCCAM (National Center for Complementary and Alternative Medicine) found that Black cohosh was not effective for relief of hot flashes and night sweats. A recent study in 2001 found that black cohosh was no more effective than "dummy" sugar pills in relieving hot flashes. The North American Menopause Society (NAMS) guidelines are not enthusiastic about this treatment because of questions about effectiveness but do not feel it is harmful to try. Most studies have been less than six months long and, therefore, the majority of experts recommend short-term use (six months or less) because there are no long-term studies of its safety.

Because black cohosh is an herbal remedy, it is not regulated by the Food and Drug Administration. Thus different preparations can contain different amounts of active drug and may have different effects on the body. If it is tried, the recommended dose is two 20 mg pills a day of a 26-deoxyactein preparation (26-deoxyactein is one of the active ingredients and is used to "standardize" the dose to make sure the right amount is taken).

Black cohosh should probably not be used in women with a history of breast cancer since it's safety has not been evaluated under these circumstances. It has an estrogen-like (female hormone) effect that, at least theoretically, could stimulate the growth of certain types of breast tumors.

Side effects appear to be uncommon and can include headaches and stomach discomfort. Other side effects are heaviness in the legs and weight problems. A few cases of hepatitis (inflammation of the liver) have been reported in people taking black cohosh but it is not clear if the herb was the cause. Because of this, some experts recommend periodic liver blood tests for people using this herb.

Black cohosh can be confused with "blue cohosh" (Caulophyllum thalictroides). Blue cohosh is sometimes used (along with black cohosh) to stimulate labor but appears to cause problems in newborns. It has no role in the treatment of menopause.

Clonidine may help treat hot flashes, but can cause quite a few side effects (drowsiness, lightheadedness, dizziness, dry mouth, constipation. low blood pressure, inhibition of orgasm, more). The North American Menopause Society (NAMS) guidelines list clonidine as a non-hormonal treatment that may be tried after antidepressants and gabapentin have been considered first and have not worked.

Hormone replacement therapy (a combination of the hormones estrogen and progestin) was previously used in many women around the time of menopause because the estrogen in the treatment was believed to help prevent heart disease, Alzheimer's disease, and bone thinning (osteoporosis).

However, a large study (the Women's Health Initiative) showed that hormone replacement therapy actually increased the risk of serious conditions including stroke, blood clots, and breast cancer. While hormone replacement therapy effectively helps prevent osteoporosis, experts have concluded that the other risks outweigh the benefits in most cases and guidelines recommend against the use of HRT solely to prevent osteoporosis.

Currently, hormone replacement therapy is recommended only for women whose hot flashes are intolerable and don't respond to other treatments. While the hormones do work to prevent bone thinning (osteoporosis), replacement therapy is not effective for treating osteoporosis once it has already developed.

Several non-hormonal medications (Fosamax/alendronate, Actonel/risodronate, Evista/raloxifen, others) are now available both for the prevention of osteoporosis and also for treatment of osteoporosis if it has already developed. They are considered safer, and according to guideline information, cause fewer side effects than HRT. Many post-menopausal women are now taking them.

Premature ovarian failure occurs when the ovaries stop producing eggs well before menopause, either for unknown reasons (most cases) or because of damage to the ovaries during chemotherapy for cancer or for chronic immune diseases like lupus.

Treatment includes taking estrogen and progestin combination pills (hormone replacement therapy) which can prevent hot flashes and bone thinning. Progestin is added to maintain the normal balance of female hormones and to protect the lining of the uterus from developing cancer (endometrial cancer).

If chemotherapy is the cause of the premature ovarian failure, hormone therapy may not be recommended because of a possible negative effect on the cancer condition. A careful discussion with your physician is usually warranted in this situation.

The risks that apply to menopausal women taking hormone replacement therapy are thought to be less for women with premature ovarian failure since these women are in a younger age category. Because this condition is not very common, there have not been many large studies to evaluate other forms of treatment.

Estrogen has been shown to increase the risk of endometrial cancer (cancer of the uterus). Studies have found that by combining estrogen with progestins (another female hormone) the uterus could be partially protected. Because of this, both estrogen and progestins are combined when hormone replacement therapy is necessary for menopausal symptoms. Estrogen, however, is typically prescribed alone (without progestins) for women who have had a hysterectomy.

Estrogen alone is effective in decreasing

Hormone therapy increases the risk of blood clots, stroke, and breast cancer. The WHI study (Women's Health Initiative, 2002), which followed 16,000 women for an average of 5.2 years (half of the women took hormone pills; the other half took a "placebo" or fake treatment) found that for every 1,000 women enrolled in the study: breast cancer developed in 3.8 of the women taking hormones versus 3.0 women on placebo. Although the increase in risk is relatively small, because of the seriousness of the condition should it develop, guidelines recommend that women keep up with their routine mammogram screening tests, particularly if they are taking hormones.

The American Cancer Society recommends annual mammograms for all women over 40, and also cautions that mammograms, even with the best techniques, can still miss some tumors, and therefore should be supplemented with breast self-exam as well as annual breast exams by a physician.

Vaginal estrogen is effective for relief of vaginal dryness and discomfort. In women who are not taking hormone pills, vaginal estrogen can be applied to the vagina directly by a tablet, cream or ring.

The Estring (estrogen ring) is a "ring" that delivers the estrogen hormone medication, and is inserted into the upper vagina by a gynecologist. It needs to be changed every 90 days. This product is effective for vaginal symptoms of dryness and pain with intercourse in women who don't find sufficient relief with over-the-counter vaginal lubricants and moisturizers. Some women prefer it instead of the daily use of estrogen cream applied directly to the vagina.

Because some of the estrogen in the cream or from the ring can get into the bloodstream, all of the precautions that are recommended for women who take estrogen pills should be followed (PAP smears, regular gynecologist exams, mammograms, etc) even though the amount of estrogen is small.

A large and important clinical study, the WHI (Woman's Health Initiative, 2002) showed that estrogen-progesterone combination pills (hormone replacement therapy) increase the risk of blood clots, stroke, and breast cancer. In addition, estrogens have a direct effect on certain breast cancer cells and can cause an increase in tumor growth. Because of this, guidelines recommend against hormone therapy in women with these conditions.

The WHI study followed 16,000 women for an average of 5.2 years - half of the women took hormone pills; the other half took a "placebo" (fake treatment). For every 1,000 women enrolled in the study:

• Breast cancer developed in 3.8 of the women taking hormones versus 3.0 women on placebo
• Stroke developed in 2.9 of the women taking hormones versus 2.1 on placebo
• Blood clots developed in 3.4 of the women taking hormones versus 1.6 women on placebo. Women who took estrogen only rather than an estrogen-progestin combination had a slightly lower increase in the rate of breast cancer.

Hormone therapy slightly increases the risk of stroke and blood clots; smoking has been shown to increase these risks as well. In fact, people who smoke are twice as likely to have strokes (and heart attacks) as people who do not smoke. Studies suggest that combining smoking with hormone therapy probably has more than an additive impact (the combined risk is greater than the sum of the individual risks), and guidelines recommend against hormone replacement therapy for women over age 35 who smoke.

Blood clots are much more likely to occur when blood is allowed to pool in one place and rather than flow at a normal pace through the blood vessels. Because of this, blood clots are not uncommon when people are at bed rest for long periods of time - for example, because of an prolonged illness, injury or following surgery. In fact, blood clots also occur during relatively short periods of immobility such as during a long airplane or car ride.

Since hormone therapy also increases the chance of developing blood clots, guidelines recommend that women who take hormone therapy carefully discuss with their health care providers the best approach that they can use to minimize the chance of blood clot development during periods of bedrest or other immobilization.

The North American Menopause Society (NAMS) guidelines mention, but no longer recommend vitamin E pills because studies are unclear about whether or not they work.

A recent analysis of the scientific literature (including the British Heart Protection Study) found that vitamin E supplements may cause an increased risk of death in people with heart disease, especially when given at higher dose. Additional studies are needed to evaluate the safety of vitamin E in healthy people as well as in those with heart problems.

These natural and herbal remedies have not been adequately studied for effectiveness in treating hot flashes. The few studies that have been performed do not show them to be effective.

Studies are currently underway to evaluate acupuncture treatment for hot flashes.

There is much controversy about "bioidentical" (or "natural") hormone replacement therapy and little data from scientific studies. "Bioidentical" hormones are over-the-counter (and a few prescription) products that are custom mixed to match a woman's naturally occuring hormone balance. These preparations differ from traditional hormone replacement therapies in two regards: first, the individual hormones are different - bioidenticals are manufactured to be chemically identical to the body's natural hormones; second, bioidenticals are often custom-mixed, combining several different types of them in proportions that are tailored to an individual woman (based on the hormone content that is measured in her saliva). Proponents of bioidentical hormones believe that, theoretically, hormone treatment that more closely matches the body's natural hormone content might cause fewer problems and side effects than "synthetic" medications.

The human body produces a mixture of more than 25 different types of "female" hormones (estradiol, estrone, estriol, progesterone, testosterone, etc). The balance of hormones differs for each woman. With traditional hormone replacement therapy, every woman receives the same hormone mixture in mass-produced pills. With "Bioidentical" hormone therapy, an attempt is made to tailor the balance (for a few of the hormones) to the individual woman, based on a test of the woman's saliva.

In addition, each individual bioidentical hormone is manufactured to be chemically identical to naturally occuring hormones. In contrast, the traditional ("synthetic") prescription hormones were intentionally designed to have a different structure so that they could be taken in pill form. Hormones that are identical to those that occur in nature, it turns out, are altered by the liver when they are ingested as pills. By slighly changing the chemical makeup, drug manufacturers were able to create pills that were still potent after ingestion. Also, naturally-occurring substances cannot be patented, but the chemically-altered substances can.

Several issues have been raised about bioidentical hormones: first, there is very little study data about the safety of effectiveness of these preparations. All of the major studies on hormone replacement therapy were performed on the traditional "synthetic" hormones. Since the bioidenticals and synthetics are chemically very similar, there is no reason to conclude that the increase in health risks from the synthetics are not shared by the bioidenticals; second, since most of the bioidenticals are not subject to scrutiny by the FDA (Food and Drug Administration), they are not monitored for quality, and impurities and dose inconsistencies have been documented; third, hormone levels vary from hour-to-hour and day-to-day and are difficult to measure - is is unlikely that a simple saliva test could accurately reflect an individual's optimal hormone balance. In addition, some bioidentical distributors have been making unfounded claims of bioidentical benefits in their advertising materials such as anti-aging properties, for example.

There are two ways that consumers have access to bioidentical hormones; they can obtain a few bioidentical drugs that have been approved by the FDA and are available by prescription (Estrace, Climara patch and Vivelle-Dot patch); or they can buy them from "compounding pharmacies" that combine over-the-counter bioidenticals based on the results of the saliva tests. The former drugs are monitored for for dose and purity by the FDA, the latter are left to the manufacturer to monitor. FDA approved skin patches are now available that deliver bioidentical hormones directly to the blood stream without having to pass through the liver (Climara patch and Vivelle-Dot patch).

Even though good studies are sorely needed to understand the risks and benefits of bioidenticals, unless the government funds them, they are unlikely to happen. The drug industry,the major source of drug research funding, would have no incentive to study products that cannot be patented. The Endocrine Society published a position paper in 2006 that hormone replacement treatments including bioidenticals be subjected to FDA regulation and scrutiny for dose accuracy, purity, and for adverse drug events. When taken as pills, these hormones are altered as they pass through the liver and therefore loose their natural chemical structure as well as a good deal of their potency.