Hello and I hope you have a happy Monday! Last week I promised new information about coping with hot flashes and night sweats, and I am so excited to share this information with you all! The North American Menopause Society (NAMS) recently reviewed Nonhormonal management alternative treatment options providing such valuable insight.
As mentioned in the first 5 parts of the Menopause Series, unfortunately many women still have a bitter taste in their mouths and fear continues to limit the use of hormone replacement therapy (HRT) after publication of the Women’s Health Initiative in 2001, (Click here to read the full Menopause Series for more information). My hope is through education and dialogue between doctors and patients we can find the best treatment options.
With an estimated 6000 women reaching menopause EVERY DAY in the U.S. it is not surprising that women are seeking alternatives to hormones to alleviate menopausal hot flashes and night sweats (also known as vasomotor symptoms). In private practice it is amazing how many pharmaceutical companies visit doctors daily to promote their newest treatment for menopausal symptoms.
It is with much excitement that I review the NAMS Position Paper (2015), about what options actually work based on current evidence.
In order for a treatment to be considered effective and safe, it must undergo a high level of scientific rigor and each alterative discussed has been “graded” according to the quality of the science.
The non-pharmacologic options that have the strongest evidence to alleviate hot flashes and night sweats or vasomotor symptoms include cognitive behavioral therapy (CBT) and clinical hypnosis. Cognitive Behavioral Therapy (CBT) involves education, breathing techniques, open dialogue about negative beliefs and assistance with sleep habits. Clinical hypnosis is a series of deeply relaxing mind-body sessions including imagery that can be done at home. If you would like to try these options, please contact trained professionals and they will help you get you started.
Non-hormone options available with only prescription include Paroxetine salt (Brisdelle) and off-label use of other anti-depressants, specifically SSRIs and SNRIs (escitalopram, citalopram, venlafaxine, desvenlafaxine, sertraline and fluoxetine). Not all of these medications work the same and many have side effects or contraindications. Talk to your gynecologist for advice specific to your situation.
Despite serious side effects including severe drowsiness, dizziness, headache and disorientation a well-known anti-epileptic medication, gabapentin and a blood pressure medication, clonidine are both proven to reduce hot flashes. Please, talk with your physician to weigh the risks and benefits for these, and all, medications.
Benefit in symptom relief has been noted for weight loss but, surprisingly, exercise without weight loss is not helpful. With so many other benefits to losing weight and the obesity epidemic in this country, taking off a few pounds should be the FIRST thing you try if your hot flashes and night sweats are getting you down.
Soy contains isoflavones that are known to bind to estrogen receptors. There are many different isoflavones, (genistein, diadzein, glycitein, biochanin A and formononetin). Since each compound binds differently to estrogen receptors and has different effects, it is very difficult to know how they work in menopause treatment. Because of the theoretical potential for treating hot flashes, many good quality studies have examined soy isoflavonoids. While studies continue, our best information to date is that placebo (no treatment) works just as well as soy and is much less expensive. There is ongoing interest in a metabolite of daidzein isoflavone called Equol that is produced by intestinal bacteria but only 30% of women can make this metabolite so studies continue.
There are some surprises in the 2015 NAMS Position Paper related to therapies that are proven unlikely to help with symptoms. This revealing list includes many I have previously advised patients to try such as black cohosh, crinum, dioscorea (wild yam), dong quai, evening primrose, flaxseed, ginseng, hops, maca, omega-3s, pine bark, pollen extract, puerparia mirifica (kwao krua, currently heavily promoted by famous gynecologist Dr. Christiane Northrup), Siberian ginseng, most vitamins and chiropractic intervention. Fortunately, there is no proven harm to trying these remedies except the cost associated with buying something that may not help. It is also important to note that many supplements included in the studies may not have contained active ingredients. Results may have been more positive if supplement quality was more standardized. (Click here to read a valuable February 2015 New York Times for more information about herbal supplement quality).
The list of techniques that should not be offered include cooling techniques, dressing in layers and avoiding “triggers” such as alcohol, spicy or hot food or liquids. Personally, I find these triggers a real issue for hot flashes even though the science doesn’t seem to support, emphasizing the importance of listening to your own body. While exercise, yoga and acupuncture have many other benefits, these therapies are NOT recommended for menopausal symptom control until further research is done.
This remains a complicated and controversial topic that is very difficult to succinctly summarize. In the spirit of open dialogue, I would be happy to answer your specific questions about menopause treatment in the comments below.
Ref: Non-hormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society (NAMS). Menopause: The Journal of the North American Menopause Society. 2015; 22(11).