Vasomotor symptoms and treatment options

Question 1

Definition of vasomotor symptoms? How does vasomotor symptoms present?

Answer 1

The sudden sensation of extreme heat in the upper body, particularly the face, neck, and chest, is referred to as a hot FLUSH, typically lasting 1–5 minutes. 
Perspiration, 
Flushing
Chills
Clamminess
Anxiety
On occasion, heart palpitations
Interfere with sleep and cause chronic sleep disruption

Question 2

Pathophysiology of vasomotor symptoms. What hormone is high and what hormone is low?

Answer 2

Changes in reproductive hormones appear to play a critical role, given that these symptoms occur during the menopausal transition and improve with the administration of estrogen.

LOW estrogen and HIGH FSH are associated with vasomotor symptoms.

The thermoregulatory zone is narrowed and becomes more sensitive to subtle changes in core body temperature. Small increases in temperature trigger thermoregulatory mechanisms causing the sensation of a hot flush (vasodilation, sweating, and decreased skin resistance).

Other central physiologic mechanisms that play a role in vasomotor symptoms include the serotonergic, noradrenergic, opioid, adrenal, and autonomic systems.

Question 3

Risk Factors of vasomotor symptoms

Answer 3

Racial and ethnic differences (physiologic differences or diets high in soy products, differing cross-cultural perceptions and reporting of vasomotor symptoms)
African American women reported the most vasomotor symptoms
Asian women reported the fewest symptoms compared with other groups.
More common in obese women
Adipose tissue functions as an insulator and interferes with normal thermoregulatory mechanisms of heat dissipation.
Adipose tissue also may have an endocrine function that mediates vasomotor symptoms.
Mood symptoms such as depression and anxiety
Low socioeconomic status
Smoking

Question 4

Treatment options: what work and what does not work

Answer 4

Works:
- Systemic hormone therapy, with estrogen alone or in combination with progestin, is the most effective therapy for vasomotor symptoms related to menopause.
- SSRIs, SSNRIs, clonidine, and gabapentin are effective alternatives to HT for the treatment of vasomotor symptoms related to menopause.
Paroxetine is the only nonhormonal therapy that is approved by the FDA for the treatment of vasomotor symptoms.

Does not work:

• Progestin-only medications, testosterone, or compounded bioidentical hormones for the treatment of vasomotor symptoms.
• Phytoestrogens, herbal supplements, lifestyle modifications, acupuncture, reflexology, nonspecific foot massage

Maybe: local injection of anesthetic into the stellate ganglion

Question 5

Difference between HRT and ERT and who should get which and why

Answer 5

HRT (estrogen + progestin) v.s. ERT (estrogen only). All women with an intact uterus need a progestin to be added to their estrogen to prevent endometrial hyperplasia, which can occur after as little as six months of unopposed estrogen.

Question 6

Risks of HRT/ERT

Answer 6

Risks of HRT (estrogen + progestin):
a slightly increased risk of breast cancer, coronary heart disease, stroke, and venous thromboembolic events
a decreased risk of fractures and colon cancer

Risks of ERT (estrogen only):
an increased risk of thromboembolic events, but not an increased risk of cardiovascular events or breast cancer
Should not be used for primary or secondary disease prevention

Question 7

Contraindications to HRT/ET

Answer 7

Contraindications to HRT/ER: a history of breast cancer, CHD, a previous VTE event or stroke, active liver disease, unexplained vaginal bleeding, high-risk endometrial cancer, or transient ischemic attack