Nonhormonal treatments offer ‘more tools in the toolbox’ for menopausal hot flashes
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Key takeaways:
- There are several nonhormonal prescription therapies for treatment of vasomotor symptoms.
- Use shared decision-making with selection tailored to the individual patient and their current medical conditions.
PHILADELPHIA — Nonhormone therapy options for vasomotor symptoms are important considerations for women who are not good candidates for or may not want to initiate hormone therapy, according to a speaker.
Menopausal HT remains the most effective treatment for vasomotor symptoms (VMS) and should be considered in women at or around the time of menopause without contraindications; however, some women may not choose to or may not be candidates for HT, Chrisandra L. Shufelt, MD, MS, FACP, NCMP, chair of the division of general internal medicine, senior consultant at the Mayo Clinic Women’s Health and associate director of the Women’s Health Research Center at Mayo Clinic in Jacksonville, Florida, said during a plenary presentation at the Annual Meeting of The Menopause Society.
An updated position statement on nonhormone therapy options from The Menopause Society includes several new recommendations and changes to reflect new evidence, namely the FDA approval of fezolinetant (Veozah, Astellas) to treat moderate to severe VMS caused by menopause.
“The evidence-based recommendations are for vasomotor symptoms — hot flashes and night sweats specifically, not insomnia, not other symptoms that go along with menopause,” said Shufelt, also the lead of the advisory board panel for the position statement.
Women who may not be good candidates for HT include those with prior estrogen-sensitive cancers; previous stroke, myocardial infarction or pulmonary embolism; or severe active liver disease.
“It is also important to respect that patients may have a personal preference not to use HT,” Shufelt said. “These women do not need to suffer in silence, and that is where this statement supports what is evidence-based out there in the literature.”
Recommended treatments
In addition to fezolinetant, recommended treatments include cognitive-behavioral therapy, clinical hypnosis, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors, gabapentin, oxybutynin, weight loss, and stellate ganglion block for select patients.
The 2023 position statement is an update to the Nonhormonal Management of Menopause-Associated Vasomotor Symptoms 2015 Position Statement that was published in Menopause.
The statement highlights several prescription therapies as nonhormonal treatments for VMS with level I (good and consistent scientific evidence) recommendations:
- Fezolinetant, the most recently approved medication, binds and blocks activities of the neurokinin 3 receptor, which impacts the brain’s body temperature regulation. Fezolinetant may not be ideal for patients with a history of headache as that has been a reported adverse event, Shufelt said, adding that clinicians should check liver function before prescribing and again at 3, 6 and 9 months. “As a practitioner, this [approval] is very exciting and is moving the class of medications forward and giving us more in our toolbox for treatments,” Shufelt said.
- Gabapentin should be initiated at a low dose and slowly uptitrated, Shufelt said. The most effective dose studied for VMS was 900 mg daily; however, the medication has been associated with adverse events including sleepiness and dizziness, so evening dosing should be considered. If adverse effects worsen, decrease the dose. “Dizziness and unsteadiness typically improve with time,” Shufelt said.
- Oxybutynin, an FDA-approved agent for overactive bladder, has been shown to reduce hot flash symptoms among menopausal women and is a new addition to the 2023 position statement, Shufelt said. There is also now a generic extended-release version of the medication available. “Since this medication is now available [for VMS], I ask all my patients about urinary urgency,” Shufelt said. “It is a common complaint during menopause, and if you have to select a nonhormone treatment, this could be a fit for both issues.” Adverse effects can include dry eyes, dry mouth and urinary difficulties. Among older adults, the medication has been associated with cognitive decline.
- SSRIs and SNRIs, including paroxetine, citalopram, escitalopram, desvenlafaxine or venlafaxine, can be used off-label for VMS in low doses and may serve as a “dual treatment” for women who report depression or anxiety during the menopause transition, Shufelt said. She cautioned that high doses can be associated with adverse effects, including hot flashes. GI symptoms can be common and the medications should be taken with food. “I always say an SSRI or an SNRI is like a shoe; it might not fit you the first time you try it and you may need to rotate to another one,” Shufelt said. For women using tamoxifen to treat or prevent breast cancer, paroxetine should be avoided.
“Bottom line, there are several prescriptions for the treatment of VMS, but only two have FDA label indications — paroxetine and fezolinetant,” Shufelt said. “The others are all for off-label use for VMS but have all been studied. Use shared decision-making and selectively tailor therapies to the patient’s needs. Ask about other symptoms that could possibly be treated concomitantly with other concerns they may have.”
Shufelt noted that two therapies included in the 2015 statement, pregabalin and clonidine, were removed as recommended treatments for VMS in the updated statement because of adverse events and controlled substance prescribing restrictions, as well as no studies showing greater benefit than placebo.
Acupuncture, other treatments
Shufelt said existing evidence does not support the use of traditional acupuncture for treatment of VMS; electroacupuncture requires more rigorous study before it can be recommended. Additionally, calibration of neural oscillations and chiropractic interventions are not recommended for VMS.
The position statement does not recommend the use of over-the-counter supplements or cannabinoids for VMS; however, clinicians should initiate a detailed discussion about both with patients, as many make take both, Shufelt said.
Stellate ganglion blockade, a recommended treatment, involves injection of an anesthetic agent by a pain specialist targeting sympathetic nerves in the front of the neck. The procedure is recommended only for select patients with VMS, Shufelt said.
“This might alleviate moderate to very severe vasomotor symptoms in select women, but it is associated with potential risk,” Shufelt said.