What Nonhormonal Therapies for Hot Flashes Actually Work?

New Position Statement from NAMS

The North American Menopause Society (NAMS) has just released their 2023 Position Statement on Nonhormonal Therapies for hot flashes and/or night sweats in menopause, also known as vasomotor symptoms or VMS. It is a good review of the state of the evidence for the myriad of nonhormonal therapies that may be offered in the office, promoted online, or stare back at you from the store shelves. I feel as if I see a new supplement for menopause almost every day, although it’s important to note this isn’t just about supplements.

Vasomotor symptoms affect up to 80% of people in menopause, and can start several years before the final period. They can be awful (for me it feels like the heat is blooming out of my head, which is why I love the old term hot blooms, because it just fits) and being constantly worried about whether you are going to break out in a sweat of not just adds another layer of joy. Waking up multiple times at night soaked in sweat isn’t just annoying, chronically disrupted sleep can have real health consequences. The average length of time someone might experience hot flashes is about 7-9 years, but that means there are some people who experience them for longer. Meaning vasomotor symptoms are a real health concern.

While estrogen is currently the gold standard for hot flashes and night sweats, not everyone can safely take hormones. For example, those who have previously had breast cancer or who are at high risk for cardiovascular disease. It’s also important to remember that not everyone feels good or hormones or wants to take them. In addition, having choices is good.

The Position Statement divides therapies for hot flashes and night sweats into these five categories:

• Lifestyle, think exercise, cooling techniques, specific diets, and weight loss.

• Mind-body techniques, such as cognitive behavioral therapy (CBT), hypnosis, paced respiration, and mindfulness.

• Prescription medications.

• Dietary supplements.

• Acupuncture and other treatments and technologies.

One very important aspect of studying interventions for hot flashes is the placebo rate is very high. A recent review of 17 studies of therapies of hot flashes tells us that a placebo can, on average, produce about 5 fewer hot flashes a day and reduce the severity of the flashes by 36%. If you look at my recent post about the new medication fezolinetant, that number is right in line with what they found for the placebo group. Meaning if someone has 10-12 hot flashes a day at baseline, a placebo might easily look like effective therapy, and if someone has 8 hot flashes a day the placebo effect can make a therapy look, well, spectacular!

While most of the studies of prescription medications for hot flashes have an appropriate placebo arm, this is rarely the case with so-called alternative therapies. In fact, the studies here are almost always low quality, so it’s often not possible to conclude much. Many reviews that look at these studies often end with a line that goes something like, “Randomized trials with a placebo arm, a low risk of bias, and adequate sample sizes are urgently needed.” You should interpret this kind of conclusion as the polite way of saying, “We need studies that aren’t bullshit to say something constructive.”

One tactic with these studies, whether intentional or due to ignorance, is measuring a lot of variables in a small number of people, because you will almost certainly get one result that is “statistically significant,” but is in reality likely a random event. So it’s important to be wary of studies with very low numbers of participants. Alternative therapies also suffer from something called publication bias, whereby only studies that show a benefit are published. However, it’s equally important to know when something doesn’t work.

Low quality studies can be twisted in many ways that seem medically meaningful, but are not. For example, marketing that says, “Supplement A reduces the severity of hot flashes by 88%,” but on a deeper dive there is no placebo arm, and while the study enrolled 76 women, only 24 appropriately completed the protocol.

People often ask why there isn’t better data on supplements and other so-called alternative therapies, like acupuncture and chiropractic care? The answer regarding supplements is they aren’t regulated like pharmaceuticals, so the manufacturers have no need. Why should a company pay for a study that might actually prove their product is useless? Better to bring it to market with some hype and a hashtag. Maybe even get a celebrity on board?! As I addressed in a recent post, it seems a supplement can easily bring in ten million dollars in sales in less than two years.

Overall, the therapies that received the highest level of recommendation in the 2023 position statement are the mind body techniques of cognitive-behavioral therapy and clinical hypnosis. For people who want a more “natural” approach, it doesn’t get more natural than harnessing the power of your own brain. The other winners were the prescription medications selective-serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin and fezolinetant (you can read about fezolinetant, which is a new drug, here). The medication oxybutynin was also recommended, but the quality of the evidence was lower, meaning this shouldn’t generally be a first choice. Also, long-term use, meaning three months or more, is associated with an increased risk of dementia. And the therapies that were still recommended, but admittedly have even lower quality evidence are weight loss and a stellate ganglion block (a nerve block).

Therapies that were in the “not recommended” category included dietary changes, paced respiration, exercise, yoga, mindfulness-based interventions, relaxation, supplements/herbal remedies, acupuncture, cooling techniques, soy foods and soy extracts, the soy metabolite equol, cannabis and cannabis-products, clonidine and pregablin (medications), and chiropractic manipulation.

I am pleased that this newest statement doesn’t quasi-legitimize understudied or unstudied therapies. What I mean is there are no nebulous recommendations along the lines of, “While studies are low quality, we find herb X to be helpful.” I think this is VERY important given how aggressively menopause is being monetized with untested diets and supplements.

I do find “cooling techniques” not being recommended as kind of funny. In fairness, this is because there is very little data, although it’s not as if you need a study to tell you that removing a layer of clothing or standing in front of an open fridge makes you feel better when your inner blast furnace kicks in. The urge to rip off a layer is real. However, in all fairness, the issue here is preventative and we don’t have good data to say that sitting in front of a desk fan, for example, reduces the risk of hot flashes even though intuitively it makes sense. Jokes aside, I think it’s great that cooling techniques aren’t recommended, because sometimes women are simply told to dress in layers as an actual therapy, and that’s insulting. My guess is most women with hot flashes have already tried wearing sleeveless shirts and done their best to employ cooling methods, and if those things worked they wouldn’t be in the office.

Regarding exercise, results are conflicting or the studies are lower quality, and that’s why it’s not recommended for hot flashes. However, exercise, both aerobic and resistance training, are both so important for a healthy menopause. Exercise is good for your heart, brain health, mood, preventing diabetes, and strengthening your bones just to name a few benefits. I always say if you can only do one thing for a healthier menopause, it’s exercise.

How well some of the prescription nonhormonal medications work and how to decide which is the best one to start could use a deeper dive as I see a lot of hesitancy here, so keep your eye out for some future posts addressing those medications. Also, I’m going to tackle one or two of the more common supplements because I think it’s good to see the data versus how these products are marketed. If you have a specific supplement you want me to discuss, please mention it in the comments!

And hopefully this position statement will make more people aware that there are some other nonhormonal options for hot flashes and night sweats.

References

1. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, Vol. 30, No. 6, 2023.

2. Zhou, Tianyu MD, MSc. Estimation of placebo effect in randomized placebo-controlled trials for moderate or severe vasomotor symptoms: a meta-analysis. Menopause 30(1):p 5-10, January 2023. | DOI: 10.1097/GME.0000000000002094.

3. Dmochowski RR, Thai S, Iglay K, et al. Increased risk of incident dementia following use of anticholinergic agents: A systematic literature review and meta‐analysis. Neurourol Urodyn. Published online October 23, 2020. doi:10.1002/nau.24536.