The Menopause Society (TMS) provided its 2023 nonhormone therapy statement at The Menopause Society 2023 Annual Conference, discussed by Chrisandra L Shufelt, MD, MS, FACP, MSCP.
Takeaways
- The Menopause Society (TMS) recommends nonhormonal therapies for treating vasomotor symptoms (VMS) in women who cannot receive hormone therapy due to various medical conditions.
- TMS suggests several nonhormonal methods for managing VMS, including weight loss, cognitive-behavioral therapy, clinical hypnosis, selective serotonin reuptake inhibitors, gabapentin, oxybutynin, fezolinetant, and stellate ganglion block.
- Exercise, yoga, and diet are not associated with significant improvements in VMS, but weight loss is indicated as a potential means of alleviating symptoms.
- Patients experiencing VMS worsened by stress can benefit from cognitive-behavioral therapy, which includes education about VMS physiology, managing emotional impact, relaxation techniques, and challenging negative beliefs about VMS.
- Prescription medications like selective serotonin reuptake inhibitors, gabapentin, oxybutynin, and fezolinetant can provide relief for VMS symptoms.
When hormone therapy is not recommended in women, nonhormonal options may be considered to treat vasomotor symptoms (VMS). Women who may be unable to receive hormone therapy include those with prior estrogen sensitive cancers, severe active liver disease, or history of stroke, myocardial function, pulmonary embolus, venousthrombosis, clotting disorder, or high risk of venous thromboembolism.
Nonhormonal methods recommended by TMS included weight loss, cognitive-behavioral therapy, clinical hypnosis, selective serotoninreuptake inhibitors, gabapentin, oxybutynin, fezolinetant, and stellate ganglion block.
Exercise, yoga, and diet have not been associated with improved VMS. However, weight loss has been indicated for improving VMS.
Certain patients may have increased VMS symptoms from stress, with physical VMS symptoms leading patients to feel self-conscious and avoid activity. These issues may be addressed through cognitive behavioral therapy. This included education about the physiology of VMS, how physical symptoms are impacted by emotions, relaxation training, paced breathing, and challenging negative beliefs about VMS.
Prescription options are also available for patients experiencing VMS. Selective serotonin reuptake inhibitors have been associated with mild to moderate improvements with VMS, and gabapentin has been associated with improvements in the frequency and intensity of VMS.
Other prescription options include oxybutynin and fezolinetant. Oxybutynin has been associated with decreased moderate to severe VMS, while fezolinetant is a first-in-class neurokinin B antagonist approved by the FDA for managing VMS.
Fezolinetant is taken through 45 mg daily doses. Headaches may be experienced as an adverse event.
Gabapentin has a recommended starting dose of 100 to 300 mg before bed and may increase to a daily dose to 600 mg or 900 mg based on a patient’s needs. Potential adverse events include unsteadiness, dizziness, and drowsiness, though these symptoms often improve over time.
The recommended starting dose for oxybutynin is 2.5 mg per day, with an increase to 5 mg twice per day after 1 week of treatment. Potential adverse events include urinary difficulties and dry mouth. Older patients may experience cognitive decline when using this medication long-term.
Selective serotonin reuptake inhibitors include paroxetine, citalopram, escitalopram, desvenlafaxine, and venlafaxine. Potential adverse events include gastrointestinal symptoms, though these often improve over time.
Prescription methods not recommended include pregabalin and clonidine. Both of these methods were associated with significant adverse events, and clonidine did not have evidence showing greater efficacy than placebo.
Over-the-counter supplements and herbs were also not recommended for managing VMS because of a lack of evidence-based research supporting their use. Other methods not recommended included cannabinoids, soy foods, extracts, and the soy metabolite equol.
There is also a lack of evidence supporting the use of traditional acupuncture against VMS. However, stellate ganglion blockade, which involves the injection of an anesthetic agent targeting sympathetic nerves in the front of the neck, has been associated with improvements in moderate to severe VMS.
Reference
Shufelt CL. Nonhormone management of vasomotor symptoms. Presented at: The Menopause Society 2023 Annual Conference, Philadelphia, Pennsylvania.
