Margaret Nachtigall, MD: Managing Menopause

The varied factors influencing menopause onset, progression, and symptom prevalence require a tailored approach to care. Luckily, there’s a deep enough tool chest, and an evidenced set of strategies, in place to ensure patients receive individualized treatment.

In an interview with MD Magazine®, Margaret Nachtigall, MD, reproductive endocrinologist and clinical associate professor in the Department of Obstetrics and Gynecology at NYU Langone Health, explained the factors and strategies involved in menopause management.

MD Mag: What are the best methods or therapies to treat menopause vasomotor symptoms?

Nachtigall: Well by far, the most efficient and effective method for treating hot flushes is estrogen therapy, and this is over the years to have been basically proven to decrease hot flushes.

And, maybe I should back up a second and just refresh the memory that hot flushes is this vasomotor instability, where patients will experience being hot and flushed at temperatures that are lower than the normal timing of sweating.

So, estrogen is a great method. Not all women can take estrogen safely—women who have had breast cancer, women who have abnormal liver function tests, or have an increased propensity to blood clotting, then estrogen wouldn't be a good option for those people. And for those women, there are other options such as antidepressant therapies, there's a marketed brand Brisdelle, which is paroxetine, which is acceptable.

And there are some over-the-counter versions that are being used. Really trying to stay cool, wearing layers, having a healthy life, eating well, exercising—these are all options that can decrease our flushes.

MD Mag: What do patients often attempt in menopause self-treatment before seeking physician care?

Nachtigall: I think that brings up a really important point, which is something that's near and dear to me, which is that every single person needs to have individual care. And what's right for one woman is not right for another patient.

So, it really depends on what their specific needs are—one, how long have they been having hot flushes; how badly are the hot flushes affecting them; is it affecting their day-to-day life; is it not; what are the other factors; what's their history been like; what are their risk factors; all of the above.

So I think that really needs to be taken into consideration before approaching what type of therapy would be best.

MD Mag: How do different patient demographics, including genetics, influence menopause symptoms, progression, and care?

Nachtigall: Well, it's interesting, because there really is no known gene that's responsible for the age of menopause. There is, of course, fragile x, which is the FMR1 gene, which when patients are carriers for this, tend to have an earlier menopause, and those are patients that present with premature ovarian insufficiency.

That being said, it is known that patients’ age of menopause has been related to the age that their mother went through menopause, and there is an earlier menopause in women who smoke.

So, those lifestyle and genetic factors are responsible for some of the decisions of when someone might go into menopause. And if someone is a genetic carrier of something that would make them predisposed to an increase in blood clot—like factor 5 deficiency or an anti-cardiolipin antibody, or another factor, protein C, protein S—that would make them more likely to have a blood clot. And then I might consider caring for them differently, and not beginning with hormone therapy or estrogen therapy.