Charity Scott, a 51-year-old trauma therapist in Los Angeles, entered menopause in May this year but has been dealing with hot flashes for about a decade.
“I was working with kids as a teacher, and they’d come up to give me a hug and be like, ‘Ew, why are you all wet?’” she recalls. “The cranial/facial sweating is the worst for me. I just looked insane and untrustworthy and nervous.” Though initially wary of hormone therapy because of her family history of aggressive breast cancer, Scott tried it for 6 months. But shortly after breaking her ankle, a “weird pain” in her right calf turned out to be a venous thromboembolism, both a rare risk of hormone therapy and a contraindication to continuing it.
She was able to continue to use a hormonal vaginal cream for vulvovaginal symptoms, but she had few other options for managing hot flashes. She couldn’t tolerate gabapentin’s side effects and couldn’t use selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) because she was already taking one. Though her friends had success with over-the-counter supplements, Scott said her health history and existing slate of medications made her “really wary of supplements because of the lack of oversight.”
So she’s been left with environmental strategies: checking and dressing for the weather, using antiperspirants along her hairline and forehead, keeping antiperspirant wipes and a neck fan with her, wearing a cooling towel like a scarf, using ice rollers on her face, and wearing cotton bra liner pads.
Scott is a perfect candidate for the nonpharmacologic approaches to managing her symptoms recommended in The Menopause Society’s 2023 updated position statement on non–hormone therapy options for managing vasomotor symptoms. Aside from evidence on effective nonhormone pharmacologic treatments — SSRIs/SNRIs, gabapentin, fezolinetant (Veozah), and oxybutynin — it includes the nonpharmacologic treatments with evidence of effectiveness: cognitive-behavioral therapy (CBT), clinical hypnosis, weight loss, and stellate ganglion block.
This article will focus on the first two options because weight loss is difficult, if well understood, and stellate ganglion block is a last-resort treatment that involves anesthesia. Although none of these showed overall effectiveness in alleviating symptoms, all performed better than placebo in studies.
Lack of Knowledge About Nonpharmacologic Options
Are physicians and other providers seeing perimenopausal and postmenopausal women aware of these other options? As a therapist, Scott knew to try mindfulness meditation and dialectical behavior therapy skills to address her distress tolerance and to reduce the emotional dysregulation associated with her symptoms. Those strategies and her “radical acceptance approach” do not change the frequency or intensity of her hot flashes, “but it changes my response to it,” she says. But she knew of those strategies because of her own professional training. No medical provider had mentioned any of the effective nonpharmacologic treatments recommended by The Menopause Society to her.
One reason for that may be how few providers in the US are certified in menopause medicine. Interest in menopause is rapidly growing, with membership in The Menopause Society swelling from around 2000 a few years ago to more than 7200 today, according to Stephanie Faubion, MD, director of the Mayo Clinic Women’s Health in Jacksonville, Florida, and medical director of The Menopause Society. But only about 2300 providers in the US have a menopause medicine certification. Primary care providers and ob/gyns therefore need to be aware that women may be seeking options beyond hormone therapy or other medications.
“A lot of times, people are interested in just taking an approach that will be less than what they consider to be invasive or aggressive in favor of something that is more natural, holistic, or gentle,” said Karen Adams, MD, a professor of obstetrics and gynecology at Stanford Medicine and director of the Stanford Program in Menopause and Healthy Aging. “Then there are people who prefer to avoid hormones or who really should not take hormones.”
Those individuals may avoid nonhormonal medications because they cannot tolerate the side effects, like Scott, or other medications are not effective for them. Or, they may have contraindications for nonhormone medications or have concerns about polypharmacy and drug interactions if they take multiple other drugs. Finally, some people may already be using hormone therapy but find it insufficient.
“Even with good pharmacologic management, we sometimes still have 10% or so residual vasomotor symptoms, so they may want to try these things in addition,” Adams said.
That’s the case for Angela Verzal, a 54-year-old office administrative worker in Houston, Texas. First, she tried Effexor XR (venlafaxine) and several supplements — DHEA, diindolylmethane, black cohosh, and ashwagandha — to manage her hot flashes. When those didn’t help, she began hormone therapy. “It did make some noticeable improvement,” Verzal said. “I can wear makeup occasionally now.” But it wasn’t enough, so her doctor increased the dose and added fezolinetant. It’s still not enough.
“My quality of life has been dramatically impacted by these hot flashes,” Verzal said. “I used