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When I started med school, estrogen was a panacea—beneficial for nearly every postmenopausal ailment: mood, heart and bone.  Then in 2002 the Women’s Health Initiative clinical trial was published.  This showed that combined estrogen with progesterone increased the risk of coronary artery disease, breast cancer, stroke and venous thromboembolism (blood clots).   Combined therapy, though, did decrease the risk of colorectal cancer, hip fractures, and total fractures.

Subsequent analysis of the data has shown that starting hormone therapy at the beginning of menopause might not increase cardiac risk compared with a start years after menopause (defined as “the stopping of menstrual periods for 6 months”) begins.

What are the options for you if you have hot flashes AND mood swings AND vaginal dryness?First, off, your physician should counsel you about the risks and benefits of hormonal therapy.  It is currently recommended that patients NOT use hormone therapy to prevent or treat cardiac disease. . . only use to decrease menopausal symptoms.

If you use hormonal therapy, consider stopping after three to five years.  Use the lowest effective dose to stop symptoms of menopause.  When you stop hormone therapy, you can taper or stop “cold turkey.”

What alternatives are there?   Numerous studies have shown the following
treatments are no better than placebo for hot flashes  acupuncture, dong quai, herbal formulations, red clover extract, kava, black cohosh, dietary soy, Chinese herbal
formulations or phytoestrogens.

What about bioidentical hormones?  Online marketing and word-of-mouth about compounded hormone formulations has increased recently.  These are unregulated formulations with unproven effectiveness or safety.  They may cause endometrial
hyperplasia (overgrowth of uterine lining tissue) which can lead to other
problems.  Patient’s should take these formulations knowing the risks and benefits.

What else is there? A few antidepressant medications decrease hot flashes by 61%.  Some specifics about this are… paroxetine is the only SSRI that has an FDA-indication for hot flashes.  But, venlafaxine, desvenlafaxine, citalopram, and escitalopram are also known to help.  Avoid sertraline or fluoxetine as these two medications within the SSRI family are not known to help.  If your hot flashes are mostly at night, gabapentin may be most helpful.

What should you do about vaginal dryness?  Estrogen cream helps with vaginal dryness and the effects have not been found to cause heart or blood clot problems.  Replens, an over-the-counter vaginal moisturizer is non-hormonal and has been shown to be as effective as vaginal estrogen for symptom relief.

Hope this helps.