Treating menopausal symptoms
Date Posted: May 1, 2008
In-Depth Report
Treating menopausal symptoms
If your menopausal symptoms cause you to seek treatment, keep in mind that just as women's symptoms vary widely, so do their responses to different treatments. What works well for a friend may be ineffective for you. You should be prepared to experiment with different strategies or regimens to find the best approach in your case.
Interest in alternatives to hormone therapy has surged, coinciding with the news about the health risks of prescription hormones. Many women prefer to try over-the-counter remedies or non-hormonal prescription drugs before considering prescription hormone treatment.
Over-the-counter products
There are many over-the-counter products to choose from to treat a variety of alleged menopausal symptoms, including herbals and "natural" or plant estrogens. Most of these products have not been well studied for effectiveness. If you choose to use over-the-counter products, it's important to know that they are not FDA-regulated. These products fall in the category known as dietary supplements; they have not undergone the scrutiny of clinical trials and are not regulated for purity of content or effectiveness. Some products may have helpful effects; others are harmless although ineffective and sometimes expensive. A few can cause serious health problems.
Phytoestrogens (plant estrogens)
Phytoestrogens are chemicals found in plants that act like weak estrogens in the body. There are three main classes of phytoestrogens: isoflavones, coumestans and lignans. They have been thought to have therapeutic properties related to menopause The fact that Asian women have fewer hot flashes compared to Caucasian women has been one of the observations fueling the notion that phytoestrogens—found in soy—might help relieve menopause symptoms Phytoestrogens have been incorporated into an array of over-the-counter products that carry many, mostly unsubstantiated, claims of effectiveness. Studies of both dietary soy and pills containing isoflavones have had mixed results.
What are bioidentical hormones? Bioidentical hormones, sometimes called "natural" hormones, are hormones that are identical to those produced by your ovaries. For estrogen, the bioidentical hormones are 17 beta-estradiol, estrone, and estriol. For progestogen, it's progesterone. Several FDA-approved products contain estradiol and progesterone. Because women respond so individually to hormone therapy, the set dosages in manufactured products may not be right for all women. With a physician's prescription, special compounding pharmacies can mix tailor-made doses of estradiol, estriol, or micronized progesterone Keep in mind that quality assurance may not be as high for compounded products as those manufactured by a large pharmaceutical company and approved by the FDA. Also, research has not proved their superiority. Some doctors who prescribe these products test a woman's hormone levels periodically, but this is of uncertain value because no one knows exactly what hormone level to aim for. Many women consider compounded products appealing partly because of numerous testimonials in the lay press, in spite of the lack of scientific data supporting this approach. |
Natural progesterone
Skin creams that contain extracts of Mexican wild yams have been widely promoted for "natural" menopause relief for years. Progesterone or progesterone-like compounds are advertised as the active ingredient. The amounts of these substances in the creams vary widely from prescription level to none at all. What's more, the amount absorbed by skin varies, so you can't be sure how much you're getting. The harms of low dose progesterone are unknown, but it may not be effective, either. Too low a dose could actually be harmful if you're relying on it to protect you from uterine cancer while taking estrogen replacement therapy. For these reasons, the North American Menopause Society does not recommend the use of nonprescription progesterone cream.
DHEA
Dehydroepiandrosterone, or DHEA, sold over the counter as a dietary supplement, also is synthesized from wild yams. In the body, the hormone DHEA is an androgen (male) hormone produced by the adrenal gland. Data on DHEA's benefits and risks are limited. Claims that DHEA supplements boost energy and mood, increase libido, aid weight loss, and delay aging have not been studied sufficiently to be confirmed or refuted. Findings on DHEA and cardiovascular disease are inconsistent. Some practitioners of complementary and alternative medicine recommend that postmenopausal women with fatigue and reduced sex drive take DHEA. But even low doses can cause such adverse reactions as facial hair growth and acne. Higher doses may cause depression, jaundice, and an increased risk of liver cancer. Long-term effects are unknown. Interestingly DHEA is not available over-the-counter in many countries outside the United States. Remember quality control of OTC products is limited.
Herbal products
The following herbs are frequently included in products marketed for treatment of menopausal symptoms.
Black cohosh
One of the most common herbs found in over-the-counter menopause supplements, black cohosh appears to relieve hot flashes and improve mood in some women. This Native American herb is sold in a pharmaceutical grade German product as Remifemin. Black cohosh doesn't appear to have estrogenic effects, although some controversy persists about this. It does not cause vaginal bleeding the way combined hormone therapy does. Side effects include stomach upset, dizziness, headache, and a low heart rate. Several incidents of serious liver toxicity have been reported, possibly as a response to contamination or to the herb itself. No long-term studies have been done.
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Black cohosh |
Red clover
Also known as Trifolium pratense, red clover is a medicinal herb originally used by Native Americans to treat whooping cough, gout, and cancer. It's also taken as a cancer treatment in many other parts of the world, and it's found in herbal preparations for skin irritation. Red clover extract has been promoted for relief of menopausal symptoms, namely hot flashes and vaginal dryness. Proponents claim that its effectiveness comes from its estrogenic effects; it is a phytoestrogen. But research results have been disappointing. Two studies published in the journal Menopause found red clover to be no better than a placebo for treating hot flashes or vaginal dryness. Red clover is on the FDA's GRAS (generally recognized as safe) list, but its long-term use has never been studied.
St. John's wort
For many years, St. John's wort has been used to treat mild to moderate depression. In studies, it has been shown to be more effective than placebo when used on a short-term basis — two months or less. A long-awaited study reported that St. John's wort is no more effective than placebo in treating major depression. Side effects include gastrointestinal problems and sun sensitivity. In addition, it can diminish or over-enhance the effects of prescription medications such as indinavir (Crixivan), warfarin (Coumadin), digoxin (Lanoxin), theophylline (Uniphyl, Theo-24, others), cyclosporine (Neoral, Sandimmune), and oral contraceptives.
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St. John's wort |
Ginkgo biloba
Studies have shown that ginkgo biloba may produce limited improvements in memory and social interactions in people with Alzheimer's disease. Some experts believe it may be useful for women with perimenopausal or postmenopausal memory problems, but there is no conclusive evidence to support such use. Ginkgo may cause stomach upset, headache, skin reactions, and prolonged bleeding. Caution is urged if it's used with anticoagulant medication. Ginkgo has been linked with bleeding in the brain when used with the anticoagulant drug warfarin. Experts also recommend that it not be used for two weeks before surgery because of the increased bleeding risk.
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Gingko biloba |
Valerian
Used as a sedative for centuries, valerian may help some women bothered by menopause-related sleep problems. It has been shown to decrease the time it takes to fall asleep and improve the quality of sleep. It may cause headaches, excitability, and heartbeat irregularities. Valerian should not be used with other sedatives, and its odor has been compared to that of old socks.
Kava
Studies have shown that kava is more effective than placebo in relieving anxiety, but the scientific strength of these studies has been called into question. Kava has been linked with liver failure and cirrhosis in reports from Germany, Switzerland, and the United States. It has been banned in several European countries and Canada but is still available in the United States. Additional side effects include gastrointestinal upset, headache, and agitation or sleepiness. It may enhance the effects of other central nervous system depressants and anticoagulants.
Ginseng
Despite its prominent place in traditional Chinese medicine, ginseng has not been found effective in treating hot flashes or any other symptoms associated with menopause. It comes with a list of side effects: insomnia, high blood pressure, prolonged bleeding time, and low blood sugar reactions if used with insulin.
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Ginseng |
Dong quai
Another common component of traditional Chinese medicine, dong quai has been used to treat a number of gynecological conditions. In one placebo-controlled study, it was not proved effective in relieving hot flashes or other menopausal symptoms, but critics of this study point out that Chinese herbs are not usually administered alone as in this study, and beneficial effects may result only from a combination of herbs as used by Chinese practitioners.
Non-hormone-based prescription drugs
Three classes of non-hormone drugs have proved at least somewhat effective in relieving hot flashes. These medications may be useful for women with troubling hot flashes who shouldn't take hormones (see "Who should avoid hormone therapy?") or who want to avoid them.
Antidepressants
Several different antidepressants appear to help ease hot flashes—and some can cause them. A study published in 2000 found that venlafaxine (Effexor), a serotonin/norepinephrine reuptake inhibitor marketed to treat depression, reduced the severity and frequency of hot flashes by more than 60%. Women in the venlafaxine study also reported being able to think more clearly and cope better with stress. And, when it worked, it was effective within a week. On the downside, some users have trouble with withdrawal symptoms when they try to stop Effexor. Another study, published in 2002, showed that fluoxetine (Prozac), a selective serotonin reuptake inhibitor, is better than placebo for relieving hot flashes. Antidepressants are often effective in relieving mood swings, depression, or anxiety that may occur at this time of life, although the doses used to treat hot flashes are lower than those usually used to treat depression. Whether one antidepressant will work for hot flashes when another has failed has not been studied, but these drugs do have different side effect profiles.
Antiseizure medication
Gabapentin (Neurontin) is FDA-approved as an antiseizure medication, but it is often prescribed to treat pain syndromes. It has shown some promise in relieving hot flashes. But gabapentin also has side effects that include blurred vision, drowsiness, nausea, tremor, and a lack of muscular coordination. When it is taken at night, it works as a sleep aid so it can be especially helpful for women with troublesome night sweats.
Antihypertensive medication
Clonidine (Catapres), a medication used to treat high blood pressure (hypertension), has been used to treat hot flashes for some time and is effective in about 50% of women who take it for this purpose. Its side effects include drowsiness, dry mouth, constipation, and insomnia, making it a less than ideal treatment.
Hormone therapy
In the past, doctors often called this hormone replacement therapy. But the levels of female hormones used to treat menopausal symptoms are lower than the usual levels produced by a woman of childbearing age. So the more correct term is simply hormone therapy.
Long the mainstay of treatment for troublesome symptoms related to menopause, hormone therapy remains the most effective treatment for hot flashes and vaginal discomfort. Some women report other benefits, such as improved joint motion and mental function. Your choices include different types of estrogens, progestogens, and androgens. Given the small but measurable increased health risks posed by hormone therapy, the current approach is to use the smallest possible dose for the shortest time possible. Your symptoms, your medical history, and your personal preferences should help determine whether you opt for hormones, and if you do, which form makes the most sense for you. In addition to choosing the type of hormone, you and your clinician also need to choose a dose and delivery method. If you require both estrogen and progestogen, you will need to determine a regimen. With help from your clinician, you can find a treatment that's optimal for you. Remember, it may take some time and patience—and possibly adjusting your regimen—to find the best approach for you.
Estrogens
Estrogen is the mainstay of hormone therapy as it is the predominant hormone that declines with menopause. Women who take estrogen therapy can expect hot flashes to decrease within the first month of treatment. It can take up to three months on a particular does to feel the maximum relief. You might have some side effects, including bleeding if you still have a uterus, nausea, breast tenderness, headache, mood swings, and changes in libido.
The majority of women in the United States take estrogen in pill form, but increasingly more are using patches, gels, lotions, spray, and even injections. Estrogen may also be taken vaginally in cream, ring, or tablet forms.
Estrogen-only (or unopposed estrogen therapy) Estrogen-alone therapy is recommended only for women who have had a hysterectomy (surgical removal of the uterus) because estrogen without progestogen increases the risk of cancer of the uterine lining (endometrial cancer). Women who still have a uterus but cannot tolerate the adverse effects of progestogen — bloating, moodiness and irritability, and sometimes spotty menstrual bleeding — may ask to try unopposed estrogen. Talk with your doctor about ways to diminish side effects from the progestogen. Any woman with a uterus who takes unopposed estrogen should have periodic vaginal ultrasounds to look for excessive growth of the uterine lining. Many doctors also recommend an annual biopsy of the lining of the uterus to check for abnormal cell growth |
Progestogens
A progestogen is a hormone that acts like natural progesterone in the body. During the menstrual cycle, progesterone prepares the uterine lining for pregnancy by increasing its blood supply. If pregnancy doesn't occur, a drop in progesterone triggers shedding of the uterine lining. In the 1980s, progestogens were added to estrogen therapy because of their ability to slough off the uterine lining. This reduces the risk of endometrial cancer associated with estrogen alone. There are different types of progestogens, and the terms are sometimes used interchangeably, which can be confusing. The term progestogen includes both synthetic forms (called progestins) and natural forms (see Table 5).
Androgens
Estrogen isn't the only hormone that declines as women age. So do androgens. Androgens are steroid hormones, often regarded as male hormones, although they occur naturally in both men and women. The two main androgens, testosterone and DHEA, play a role in maintaining sexual desire, muscle mass, bone density, fat distribution, mood, energy, and feelings of well-being. Some clinicians think there are situations that may justify a trial of androgen supplements. Examples include removal of the ovaries, which causes an abrupt drop in estrogen and androgen production, or low sex drive that does not improve with estrogen. But the indications, risks, and benefits are uncertain at best, and there are no long-term data on the use of testosterone in women. The only FDA-approved testosterone product for women is a form of testosterone combined with estrogen and approved only for hot flashes.
Some experts have described an "androgen deficiency syndrome" in women marked by low androgen levels, low energy, and reduced sex drive. Even though laboratory testing can measure your androgen levels, the values are often not accurate because the tests are standardized to normal male values, which are far higher than those found in women. There is little information to guide physicians in determining the appropriate blood levels of androgens for women at various stages in their lives. It's still not clear if and how women might benefit from androgen replacement therapy, but ongoing research may help clarify the situation. A testosterone patch for women manufactured by Proctor and Gamble did not pass the FDA's scrutiny but has been approved in Europe
Choosing a health care provider Maybe your periods have become irregular, or you've just started to feel the heat of hot flashes. It's important to consult a health care provider who will listen to your concerns and work with you to determine the best options for symptom relief and disease prevention. Most primary care doctors can diagnose menopausal symptoms, guide you in anticipation of symptoms, and help you find appropriate treatments if you need them. Still, some physicians are more knowledgeable about menopause than others. If your physician's recommendations don't relieve your symptoms and your doctor isn't able to answer all the questions you have about what is going on or which treatments are right for you, it may be time for a specialist. Asking your doctor for a referral is probably the best place to start. A gynecologist or endocrinologist may be a good choice. Clinics that specialize in women's health are often oriented toward helping devise a strategy for treating symptoms specific to women and reducing their disease risks. Ask friends who have been to a specialist if they would recommend the doctor they've seen. The North American Menopause Society (NAMS) also has referral lists of its members in the United States and Canada at www.menopause.org, including those certified as a NAMS Menopause Practitioners. |
Combined hormone therapy
Combined hormone therapy usually refers to the combination of an estrogen and a progestogen, used to treat menopausal symptoms without increasing the risk of uterine cancer. You have several choices for combined hormone therapy. You can take the combination of an estrogen and a progestogen in a single pill (Prempro) or patch, or take estrogen and progestogen separately in pills, patch, a pill and a patch, or a pill and a gel (see Table 4), among other options.
Symptom relief from combined hormone therapy is much the same as it is for estrogen alone. Symptoms will improve in the first month, but the maximum effect may take up to three months. You may have intermittent bleeding after starting combined hormone therapy. Side effects from the progestogen include acne, bloating, weight gain, and mood swings. Not all women will respond the same way, so the doses or types of both hormones may have to be adjusted. Taking the estrogen and progestogen components separately enables you to tailor your doses to your specific needs.
Hormone regimens
Depending on your health history and personal preferences, you have several hormone regimens to choose from.
Low-dose oral contraceptives. Some doctors prescribe low-dose oral contraceptives to relieve menopausal symptoms and regulate periods while providing contraception during perimenopause. If you smoke or have high blood pressure, choose something other than birth control pills for these purposes, because they can increase your risk of heart attack and stroke. Some women prefer to skip the placebo pills in each monthly pack, taking hormones all month; this eliminates the period that normally occurs at the end of each month's pill cycle, and therefore lets them avoid symptoms such as migraines or hot flashes that can occur during the placebo week.
Cyclic hormone therapy. This combination of estrogen and progestogen is often the best choice for women who are menstruating occasionally or have stopped recently. It mimics the body's natural premenopausal cycle and gives the endometrium an opportunity to slough off regularly so it does not build up and cause disturbing bleeding or become cancerous. The regimen involves taking estrogen every day and adding the progestogen for 12 or 14 days per month. Cyclic hormone therapy helps regulate periods and relieve symptoms during the erratic hormonal fluctuations of late perimenopause. However, in late menopause, women may still have estrogen surges. Because a woman can't predict the timing of a surge, cyclic therapy could potentially make symptoms worse.
Continuous combined hormone therapy. This method of combined hormone therapy uses a constant dose of estrogen and progestogen taken every day. The daily progestogen dose is lower than that for cyclic hormone therapy. The goal is to eliminate periods completely. However, many women have some bleeding or spotting for the first six months to a year of using this method. This sporadic bleeding is one reason some women don't stay on continuous combined hormone therapy for long.
Constant estrogen, pulsed progestogen. This regimen, packaged in a single product, consists of only estrogen for three days followed by three days of combined estrogen and progestogen. You continue on in that pattern for as long as you take the medication. Protection from uterine cancer is about the same as with continuous combined hormone therapy, but this method offers greater benefits on cholesterol levels. Erratic vaginal bleeding still may occur while taking this product.
Tapering off hormones Because current research suggests that it's best for women to take the lowest dose of hormones for the shortest possible time, many clinicians advise women to try weaning themselves off the drugs after a year or less, although many stay on the medications for several years or longer. A follow-up study of participants in the Women's Health Initiative who stopped their hormones abruptly found that among women who had symptoms before starting the study hormones, more than half said their symptoms returned after stopping hormones. On the bright side, many found that a range of strategies (mostly lifestyle changes such as drinking more fluids, exercising, and using fans or air conditioners) was helpful in relieving or coping with symptoms. There's little known about the best way to stop hormones, and there is no established regimen for doing so. Nor is there evidence that tapering can stave off the recurrence of symptoms. However, if you and your doctor agree that tapering off hormones is a good approach, try tapering during the winter rather than summer, when hot flashes tend to be worse. If possible, start during a low-stress time (not, for example, during or soon after any other major life transitions). If you take both estrogen and a progestogen separately, be sure to reduce the dose of both hormones. The specific strategy depends partly on the form you're taking. With pills, you can either skip a day or two or cut the pills in half. Skipping works better with certain pills than others because of how long the medicine stays in your system; your clinician can help determine this for you. Most patches can be trimmed with scissors. Stay on the lowered dose for five to six weeks (which is how long it takes your body to adjust), then drop down a little further. This slow tapering process can help you determine the lowest possible dose needed to relieve your symptoms, in the event that you end up needing to stay on the hormones a little longer. Vaginal symptoms tend to appear and disappear more slowly than hot flashes. Remember that you can use local estrogen, in the form of creams, tablets, or a ring, for vaginal symptoms. For more specific suggestions, consult your clinician. |
Patches, creams, rings
In addition to pills, there are a variety of other ways to take hormones. Patches, skin creams, gels, and one brand of vaginal ring (Femring) all contain hormones that work systemically to treat symptoms of menopause. With each of these, women with an intact uterus should use a progestogen in addition to the systemic estrogen. For women troubled mainly by vaginal dryness and who want to avoid the potential risks of systemic estrogen, there are estrogen products designed to maximize the vaginal effects and minimize absorption, including vaginal creams, vaginal tablets, and a ring (Estring).
Patches. Several brands of patches that deliver estrogen through the skin are available. Patches are worn discreetly on the abdomen or buttocks. Most of the patches marketed in the United States contain a form of estrogen called estradiol, in doses ranging from 0.025 mg to 0.1 mg. Estradiol is "bioidentical" enters the bloodstream rapidly, quickly reaching target tissues.
One type of patch is the reservoir patch, which has a waterproof backing and a small supply of the drug suspended in alcohol. The alcohol carries the drug through a membrane in the patch and into the skin. Another type is the matrix patch, which delivers estrogen through a layer of gel. This type of patch is thinner and less bulky than reservoir patches. Also, it can be cut with scissors if you want to reduce the amount of hormone delivered — a technique often used to taper off hormone doses.
Patches contain less estrogen than pills because the hormone isn't broken down by digestion. This probably reduces the risk of gallstones. One benefit of patches and other transdermal hormones is that they do not pass through the liver. As a result, unlike estrogen in pill form, patches and other transdermal products do not increase the levels of several proteins including sex-hormone-binding globulin. This hormone binds with testosterone, which result in a lower sex may drive—a potential problem in women who take oral estrogens.
Combination patches are available containing both estrogen and progestogen, but if you want to adjust the doses, you will need to take the estrogen and progestogen separately. Women with sensitive skin may find patches cause irritation. If you notice any skin irritation, report it to your doctor. Usually each patch is effective for three to seven days. Patches are usually more expensive than pills, but a less expensive generic estrogen patch is available. Price may depend on your insurance carrier.
If you use the patch Make sure the skin where you will place the patch is clean and dry. Wait half an hour after bathing before applying the patch. This will help it adhere better. Alternatively, dry the area lightly with a hair dryer or wipe the skin with alcohol and allow it to air dry. Place the patch on your abdomen or buttocks, where absorption is best. Alternative locations are the upper arm, thigh, or back. Never apply to your breast. Carefully pull away half of the backing and apply the patch to your skin without touching the adhesive. Carefully remove the rest of the backing and press that section to your skin. Gently rub the patch with your fingers in a circular pattern for several seconds to make sure the edges are well adhered to your skin. If the patch starts to lift while you are wearing it, apply a small piece of first-aid tape to keep it in place. Each time you apply a new patch, choose a different spot. Apply over-the-counter hydrocortisone cream after removing the patch to soothe the skin. If you notice any redness or irritation at the site of the patch, report it to your clinician. |
Transdermal gels and creams. There are three gels, which come in a clear, odorless, alcohol-based form that's delivered either from a metered-dose pump or packets You apply the gel once a day on one arm from the wrist to the shoulder. The gel dries completely in two to five minutes. Another product, Estrasorb, is a topical emulsion that you rub into your thighs and buttocks; it comes in individual foil packets. Evamist is a spray that comes in a dispenser and is spayed onto your arm.
Vaginal rings. These products are inserted into the vagina, much like a contraceptive diaphragm. The ring releases estrogen gradually and needs replacement about every three months. One brand, Estring, produces only local effects, and is appropriate for women who want to treat only vaginal symptoms. A different brand, Femring, contains higher doses of estrogen and treats hot flashes in addition to vaginal dryness. Although the rings can be removed temporarily and reinserted, neither type has to be removed before sexual intercourse.
Vaginal creams. Vaginal creams treat only the local tissues of the vagina and typically do not treat systemic symptoms such as hot flashes. Because they are not systemic, vaginal creams do not carry the same benefits and risks as estrogen taken by pill or patch. Only small doses are needed to relieve vaginal dryness, a plus for women who want to relieve vaginal symptoms and avoid risks associated with higher doses of estrogen. If you have a uterus, you probably do not need to take a progestogen with a vaginal cream, but you may want to discuss this with your doctor. Even though these estrogen products are used in the vagina, they can enter the bloodstream if a large enough dose is used. Estrogen cream should not be used as a lubricant before intercourse; it's been known to be absorbed through a partner's skin.
Vaginal tablets. Estrogen tablets are inserted into the vagina with an applicator to relieve vaginal symptoms. Like the vaginal creams, this product can relieve dryness and irritation.
Who should avoid hormone therapy?
Because of the risks associated with hormone therapy, women with the following health conditions generally should not take hormones:
heart disease
breast, ovarian, or endometrial (uterine) cancer
stroke, deep-vein thrombosis, pulmonary embolism, or blood-clotting disorders
liver disease
unexplained vaginal bleeding
known or suspected pregnancy.
The risk of hormone therapy for women with a family history of breast cancer or heart disease is unknown. Women with a family history of blood clots in the legs or lungs (deep vein thrombosis, pulmonary embolism) might be advised to do blood testing prior to starting hormone therapy.
Coping with side effects of hormone therapy |
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As with all medications, hormones may cause unwanted side effects. Here are some tips for minimizing some of the most common. |
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Side effect |
Coping strategy |
Fluid retention, including swollen feet, ankles, hands, or abdomen |
Cut back on salt, drink plenty of water, consider taking a mild diuretic (herbal or prescription). |
Abdominal bloating or gas |
Try lowering the dose of either hormone; switch to another estrogen/progestogen; try a skin patch instead of a pill. |
Headaches |
Cut down on salt, caffeine, and alcohol; drink plenty of water; lower estrogen, progestogen, or both; avoid MPA; switch to a continuous schedule or a patch to minimize hormone fluctuations. |
Breast tenderness |
Cut down on salt, caffeine, and chocolate; lower the estrogen and or progestogen dose or try a different one. |
Mood changes |
Cut down on salt, caffeine, and chocolate; drink plenty of water; switch to progestogen or try a different one; switch to a continuous regimen or a patch to avoid hormonal fluctuations; exercise regularly. |
Nausea |
Take pills with meals or in the evening before bedtime; switch to a lower estrogen or progestogen dose; try a different oral estrogen; switch to a patch. |
Skin irritation under the patch |
Keep skin under patch very clean; switch to a patch with a different adhesive; apply patch to a different area; switch to oral estrogen. |
Other possible side effects include uterine bleeding, dizziness, and changes in the shape of the cornea, which make it difficult or impossible to wear contact lenses. |
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Review Date: 2008-05-01
Harvard Medical School does not endorse products or services.
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