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NAMS weighs in on behavioral therapies, nonhormonal drugs for hot flashes

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September 24, 2015

The North American Menopause Society formally recommended certain alternative therapies to manage menopausal vasomotor symptoms, including cognitive behavioral therapy and clinical hypnosis, as well as several prescription nonhormonal drugs, according to a new position statement published in Menopause.

In an expansion on what was previously part of a larger position statement on the management of vasomotor symptoms, more commonly known as hot flashes, researchers also noted that evidence for other nonhormonal methods or treatments, including herbal remedies, acupuncture and chiropractic care, is insufficient or inconclusive and should not be considered as hot flash remedies.

“Many women try one thing after another, and it is months before they stumble upon something that truly works for them,” Janet S. Carpenter, PhD, RN, FAAN, chair of the Indiana University School of Nursing in Indianapolis, said in a press release.

In recommending two mind–body approaches, the North American Menopause Society (NAMS) statement noted that randomized controlled trials show a cognitive behavioral therapy approach — combining relaxation techniques, sleep hygiene and learning how to take a positive approach to symptom management — was significantly effective in reducing the magnitude, although not the number, of hot flashes. Randomized controlled trials also showed clinical hypnosis to be significantly better than a “structured attention” therapy approach in postmenopausal women with hot flashes.

The researchers also recommended with caution a soy derivative under study, S-equol, and stellate ganglion block, as well as weight loss and stress reduction.

Selective serotonin reuptake inhibitors (SSRIs), including paroxetine, and serotonin-norepinephrine reuptake inhibitors (SNRIs), including venlafaxine, may also offer mild to moderate improvements, the researchers wrote, although they may not offer as much relief as hormone therapy.

Researchers outlined several therapies that are unlikely to benefit women experiencing hot flashes, including over-the-counter herbal supplements, such as black cohosh, evening primrose or ginseng, and calibration of neural oscillations and chiropractic intervention.

Exercise, yoga, acupuncture, cooling techniques and avoiding hot flash “triggers,” such as alcohol, were described by researchers as ineffective therapies that may appear risk-free, but can ultimately delay treatment.

“Until evidence from well-controlled trials is available, these therapies should not be recommended for [vasomotor symptoms],” the researchers wrote.”

The statement follows a formal recommendation from NAMS in June that HT be considered for women older than 65 years, citing recent research on longer-lasting menopausal symptoms and a lack of effective treatment alternatives. HT, including oral and transdermal estrogens, remains on the list of potentially inappropriate medications for women older than 65 years, more commonly known as the Beers criteria. by Regina Schaffer

Disclosure: Carpenter reports no relevant financial disclosures. Please see the position statement for all other authors’ relevant financial disclosures.

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Richard Santen

Richard Santen

In randomized controlled trials, 30% of women with hot flashes respond to placebo, both with a decrease in hot flash number and hot flash score. The FDA, most publications and physicians only consider the efficacy of the selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) agents to be the difference between placebo and drug; for example, a 30% reduction in the placebo group and a 70% reduction in treatment group. The FDA and most physicians consider this a 40% reduction and, therefore, only mildly or moderately effective. However, a woman being treated does not care if the effect is physiologically due to placebo or due to drug. She cares that her symptoms are improved. Bottom line, the SSRIs and SNRIs reduce symptoms overall by approximately 70%. The Up to Date guidelines that Charles LoPrinzi and I wrote suggest that hypnosis and mind/body measures require more study and caution, and we would not recommend them as strongly as the North American Menopause Society (NAMS) guidelines. The NAMS statement does not appear to distinguish mild from moderate or severe hot flashes. For mild hot flashes, avoiding stress, hot rooms, dressing in layers and using fans are useful. This requires emphasis. Soy and the other agents listed may work as placebos and probably benefit some women, and agents such as black cohash require more study.

Richard Santen, MD
Professor of Medicine, division of endocrinology and metabolism
University of Virginia Health Sciences System
Charlottesville, Virginia

Disclosure: Santen reports no relevant financial disclosures.