Managing women during the menopause

It should be noted that there are various ways to treat women experiencing symptoms of menopause. 
Conservative measures can be tried initially.  Lifestyle modifications to help with hot flushes and night sweats include regular exercise, weight loss, lighter fitting clothing, keeping the environment at a lower temperature, reducing stress and avoiding triggers such as caffeine, smoking, alcohol and spicy foods. Sleeping problems might be helped by avoiding exercise late in the day and having a regular bedtime. Mood can be elevated by physical activity, relaxation techniques and ensuring adequate sleep. 
If HRT is contraindicated or the women does not wish to take it, there are other non-hormonal options that can be given. For vasomotor symptoms, 20mg fluoxetine daily, 20mg citalopram daily or 37.5mg venlafaxine twice daily can be tried. However, it should be noted that these are off-label use and so efforts should be made to consider withdrawal of treatment if women have been symptom-free for 1-2 years. Women experiencing fluctuating mood may be referred to self-help groups, for cognitive-behavioural therapy or offered antidepressants. However, it should be explained that there is no actual evidence for using antidepressants to improve mood in menopausal women who do not have a diagnosis of depression. For vaginal dryness, a vaginal lubricant or moisturiser such as Replens MDÒ can be used indefinitely if needed. Women with urogenital atrophy (even if already taking HRT) may be offered low-dose vaginal oestrogen and should be told that if this is stopped, symptoms will often recur. For women experiencing sexual dysfunction, specialist advice could be sought about using testosterone supplements. 
Some women may ask about complimentary therapies, but it should be advised that there is a lack of evidence around their use. There is limited evidence that isoflavones and black cohosh have positive effects on vasomotor symptoms, but their safety profile is unknown and different preparations may vary. There is a potential that gabapentin might effectively reduce hot flushes, however ongoing work is looking into this further. Beta-blockers should be avoided because there has been no established data confirming their effectiveness in treating menopausal symptoms. 
A review of the woman should be scheduled at 3 months to assess for effectiveness of treatment, reinforcing lifestyle advice and considering withdrawal of treatment if ineffective or any side-effects. 



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