Nonhormonal Management of Menopause-associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society

The North American Menopause Society (NAMS). 2015;22(11):1155-1174. 

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These recommendations are based on the evidence reviewed ( Table 4 ). Because most trials were between 8 and 24 weeks’ duration, data on long-term use are limited.

  • Considerations when stopping or switching therapies: Evidence from relatively short-term pharmaceutical trials (eg, 8-12 wk) suggests that there is a return of VMS when treatment is stopped. However, there are no available data on potential effects of withdrawing SSRIs or SNRIs after a period of 2 to 3 years when used for VMS in nondepressed women. Similar evidence is not available from nonpharmacologic, nonhormonal intervention trials.

  • Recommended nonpharmaceuticals: Two mind-body therapies have level I evidence showing efficacy in alleviating VMS: cognitive-behavioral therapy according to the MENOS 1 and MENOS 2 protocols and clinical hypnosis according to the Elkins protocol. These are relatively risk-free therapies. Women may need education and help in weighing potential benefits against barriers, such as time commitment and difficulties in finding appropriately credentialed providers.

  • Recommended pharmaceuticals: Nonhormonal effective pharmacologic therapies include the FDA-approved lowdose paroxetine salt at 7.5 mg/d and off-label use of other antidepressants (SSRIs and SNRIs), gabapentin or pregabalin, and clonidine.

    • For all therapies, the lowest dose should be tried first and then titrated up as needed to avoid or minimize adverse events. Onset of action is rapid, usually within 2 weeks.

    • With titration, these agents are usually well tolerated. Contraindications include hypersensitivity or prior adverse drug reactions. VMS often improve over time, and limited evidence from clinical trials suggests that nonhormonal therapy should be gradually tapered over 1 to 2 weeks to avoid drug withdrawal symptoms.

    • No clear recommendations can be given for efficacy of one nonhormonal prescription therapy over another because there are few head-to-head comparison efficacy trials, and trials have a varying number and severity of hot flashes.

    • Choice of therapy depends on prior effective and tolerated therapy, patient history, adverse events profile, coadministered medications or benefit of drowsiness as an adverse effect (gabapentin), coexistence of a mood disorder, whether hot flashes are more bothersome during day or night, sensitivity to medications, patient tolerance of potential adverse effects, pharmacogenetic testing, and patient preference.

    • Therapy should be carefully re-evaluated on a regular basis (eg, every 6-12 mo) because data on long-term use are limited.

  • Recommend with caution: Some therapies have level II evidence suggesting that they may be beneficial for alleviating VMS: weight loss, mindfulness-based stress reduction, the S-equol derivatives of soy isoflavones and extracts, and stellate ganglion block. Additional studies of these therapies are warranted.

    • Women are likely to be able to access weight loss programs and mindfulness-based stress reduction programs within their communities. Women may need education and help weighing barriers of time and cost in relation to potential benefits. These therapies may not be best for women with severe VMS or those seeking immediate relief.

    • In postmenopausal women with mildly to moderately distressing hot flashes, the S-equol derivatives of the isoflavones may be a reasonable option, providing there is no history of soy intolerance or allergy. If a woman responds to S-equol supplementation, treatment can continue with monitoring for adverse events; if a woman does not respond after 12 weeks, other treatment options should be discussed. Severely distressing hot flashes will be relieved more effectively with prescription therapies. Shared decision making is valuable in this setting.

    • Overall, although benefits were reported from single trials investigating a phytoestrogen extract from the rhubarb plant (ERr 731) and an equol supplement (SE5-OH), data were insufficient to permit determination of whether any other type of phytoestrogen product had significant effects on VMS.[67]

    • Stellate ganglion block may be an option for some women.

  • Do not recommend at this time: Several therapies have level II or lower evidence showing that they are unlikely to be beneficial in alleviating VMS: over-the-counter supplements and herbal therapies (including black cohosh, crinum, dioscorea, dong quai, evening primrose, flaxseed, ginseng, hops, maca, omega-3s, pine bark, pollen extract, puerperia, Siberian ginseng, and vitamin supplementation), as well as relaxation, calibration of neural oscillations, and chiropractic intervention. Until additional evidence from well-controlled trials is available, these therapies should not be recommended for VMS.

  • Do not recommend at this time: Some therapies appear risk free but do not have any evidence testing their effects on VMS, and their use may lead to delay in receipt of more appropriate and efficacious treatment. These include cooling techniques and avoidance of ‘‘triggers.’’ Research testing these recommendations is warranted.

  • Do not recommend: Several therapies have level I evidence that shows that they are unlikely to alleviate menopausal VMS: exercise, yoga, paced respiration, and acupuncture. Although there are many health benefits associated with these, attempts to use these therapies are likely to delay receipt of more appropriate and effective therapies. In symptomatic women, such delays should be avoided given the association of VMS with other symptoms and overall quality of life. Exercise, yoga, and paced respiration should not be recommended for relief of VMS.