Experts say hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and should be considered for healthy menopausal women within a decade of their final menstrual periods – despite new options in non-hormone-based treatments.
A scientific review also found that options like acupuncture, soy foods and cannibinoids, are ineffective, and along with a group of other alternatives, might even have adverse effects, reports MDEdge.
In an updated position statement from the North American Menopause Society in its first review of the scientific literature since 2015, the association specifically targets the management of symptoms like hot flushes and night sweats, which afflict many as 80% of menopausal women but are under-treated.
The statement was published in the Journal of The North American Menopause Society.
“Women with contraindications or objections to hormone treatment should be informed by professionals of evidence-based effective non-hormone options,” said the NAMS advisory panel led by Dr Chrisandra Shufelt, professor and chair of the division of general internal medicine and associate director of the Women’s Health Research Centre at the Mayo Clinic in Florida.
Research has changed, she said, “and we wanted to make clinicians aware of new medications”.
“One of our interesting findings was more evidence that off-label use of the non-hormonal overactive bladder drug oxybutynin can lower the rate of hot flushes.”
She added that many of the current update’s findings were aligned with previous research, and stressed that the therapeutic recommendations applied specifically to VMS.
“Not all menopause-related symptoms are vasomotor, however. While a lot of the lifestyle options such as cooling techniques and exercise are not recommended for controlling hot flushes, diet and exercise changes can be beneficial for other health reasons.”
Although it’s the most effective option for VMS, hormone therapy is not suitable for women with contraindications such as a previous blood clot, an oestrogen-dependent cancer, a family history of such cancers, or a personal preference against hormone use, she added, so non-hormonal alternatives are important to prevent women from wasting time and money on ineffective remedies.
Recommended non-hormonal therapies
Based on a rigorous review of the scientific evidence to date, NAMS found the following therapies to be effective: cognitive-behavioural therapy; clinical hypnosis; SSRIs and serotonin-norepinephrine reuptake inhibitors – which yield mild to moderate improvements; gabapentin – which lessens the frequency and severity of hot flushes; fezolinetant (Veozah), a novel first-in-class neurokinin B antagonist that was US Food and Drug Administration–approved in May for VSM; and oxybutynin, an antimuscarinic, anticholinergic drug, that reduces moderate to severe VMS, although long-term use in older adults may be linked to cognitive decline, weight loss and stellate ganglion block.
Therapies that were ineffective, associated with adverse effects (AEs), or lacking adequate evidence of efficacy and thus not recommended for VMS included: paced respiration; supplemental and herbal remedies such as black cohosh, milk thistle and evening primrose; cooling techniques; trigger avoidance; exercise and yoga; mindfulness-based intervention and relaxation; suvorexant, a dual orexin-receptor antagonist used for insomnia; soy foods, extracts, and the soy metabolite equol; cannabinoids; acupuncture; calibration of neural oscillations; chiropractics; clonidine, an alpha-2 adrenergic agonist that is associated with significant AEs with no recent evidence of benefit over placebo; dietary modification; and pregabalin – which is associated with significant AEs and has controlled-substance prescribing restrictions.
Ultimately, clinicians should individualise menopause care to each patient. For example, “if a patient says avoiding caffeine in the morning stops her from having hot flushes in the afternoon, that’s fine,” she said.
HT still most effective
Dr Jill Rabin vice chair of education and development, obstetrics and gynaecology, at Northshore University Hospital/LIJ Medical Center in Manhasset, and professor of obstetrics and gynaecology at Hofstra University, who was not involved in compiling the statement, said she regularly prescribes hormone therapy for VMS for suitable candidates.
Regarding non-hormonal options, she added that some of those not recommended in the NAMS statement could still prove to be effective as more data accumulate. Suvorexant might be one to watch, for instance, but currently there are not enough data on its effectiveness, she said.
Further, she said there was little harm in lifestyle and alternative remedies of unproven benefit.
“As far as I know, no one’s ever died of relaxation and paced breathing.” In addition, a patient’s interaction with and sense of control over her own physiology provided by these techniques may be beneficial in themselves.
Study details
The 2023 non-hormone therapy position statement of The North American Menopause Society
Objective
To update the evidence-based non-hormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The NAMS
Methods
An advisory panel of clinicians and research experts in women’s health were selected to review and evaluate the literature published since the Non-hormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society. Topics were divided into five sections for ease of review: lifestyle; mind-body techniques; prescription therapies; dietary supplements; and acupuncture, other treatments, and technologies. The panel assessed the most current and available literature to determine whether to recommend or not recommend use based on these levels of evidence: Level I, good and consistent scientific evidence; Level II, limited or inconsistent scientific evidence, and Level III, consensus and expert opinion.
Results
Evidence-based review of the literature resulted in several non-hormone options for the treatment of vasomotor symptoms. Recommended: Cognitive-behavioural therapy, clinical hypnosis, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors, gabapentin, fezolinetant (Level I); oxybutynin (Levels I-II); weight loss, stellate ganglion block (Levels II-III). Not recommended: Paced respiration (Level I); supplements/herbal remedies (Levels I-II); cooling techniques, avoiding triggers, exercise, yoga, mindfulness-based intervention, relaxation, suvorexant, soy foods and soy extracts, soy metabolite equol, cannabinoids, acupuncture, calibration of neural oscillations (Level II); chiropractic interventions, clonidine; (Levels I-III); dietary modification and pregabalin (Level III).
Conclusion
Hormone therapy remains the most effective treatment for vasomotor symptoms and should be considered in menopausal women within 10 years of their final menstrual periods. For women who are not good candidates for hormone therapy because of contraindications (eg, oestrogen-dependent cancers or cardiovascular disease) or personal preference, it is important for healthcare professionals to be well informed about non-hormone treatment options for reducing vasomotor symptoms that are supported by the evidence.
See more from MedicalBrief archives:
FDA approves pill for menopausal hot flushes
The role of diet in menopausal hot flushes
HRT should be given earlier as menopause ‘reshapes the brainʼ – Nature Scientific Reports
New drug cuts number and severity of hot flushes