What works for treating hot flushes and night sweats apart from HRT? The North American Menopause Society’s 2023 nonhormone therapy position statement has the answers.

When it comes to treating vasomotor symptoms, we need to know what works. We know hormone replacement therapy (HRT) does work, but if you can’t or don’t want to take that for your hot flushes or night sweats, what are your options?

The North American Menopause Society recently updated its 2015 advice on what works and what doesn’t and the 2023 version has some changes from it’s 2015 predecessor. You can access it here.

To come up with the recommendations an advisory panel made up of a team of doctors and scientists went literally hundreds of studies published since the first publication 8 years ago, evaluating them based on the quality of the studies and whether they have good levels of evidence behind them.

The panel assessed the literature to determine whether to recommend or not recommend use based on these levels of evidence:

• Level I, good and consistent scientific evidence
• Level II, limited or inconsistent scientific evidence, and
• Level III, consensus and expert opinion.

They divided topics into five main areas:

• lifestyle – for example exercise, yoga and diet
• mind-body techniques, like mindfulness and CBT
• prescription therapies (other than HRT as it is already recommended)
• dietary supplements – herbal, botanical or other other supplements
• acupuncture and other treatments/technologies such as cooling pads or sprays.

This is what they recommended for the treatment of vasomotor symptoms – and remember they were only looking at the effects they had on these symptoms – reducing the number of or severity of hot flushes and night sweats.

What’s on the ‘Yes’ list?

Under lifestyle the panel recommended:

• Cognitive-behavioural therapy (level I) – therapies that help you change your perception of the vasomotor symptoms
• clinical hypnosis (level I) – they noted this should be done in person and by a qualified practitioner. The apps/home hypnosis devices didn’t perform as well
• losing weight (levels II-III)

Under non-hormone medications the panel recommended:

• selective serotonin re-uptake inhibitors (SSRI)/serotonin-norepinephrine re-uptake inhibitors (SNRI) (Level I) – antidepressants which when given in a low dose helps regulate serotonin and serotonin is involved in temperature regulation
• gabapentin (level I) – an anti-anxiety medication
• fezolinetant (level I) – a neurokinin 3 receptor antagonist treatment recently approved by the FDA and awaiting approval in the UK
• oxybutynin (Levels I-II). This is a drug used for overactive bladder but as a side benefit of reducing the number and severity of hot flushes.

Under ‘other treatments’ the panel recommended:

• stellate ganglion block (Levels II-III). This involves a pain killer being injected into a block of nerves in the neck, usually for pain control reasons, but has been found to coincidentally help with vasomotor symptoms. (It may be hard to find someone to do this in the UK for vasomotor control.)

What’s on the ‘No’ list?

Now,  I know not everyone will like or agree with these findings – but don’t shoot the messenger. If they work for you, that’s great, but the evidence at this stage (and I say ‘at this stage’ as evidence evolves, which is why they’ve done this new position statement up-dating the 2015 version) shows that they don’t work well for everyone or don’t have robust evidence behind them.

So, under lifestyle the ‘not recommended’ activities are:

• avoiding triggers
• exercise
• yoga
• mindfulness-based intervention
• relaxation techniques
• dietary modifications.

That doesn’t mean that exercise, yoga or eating better aren’t great for other things, but they weren’t shown to have helped with reducing the number of or severity of night sweats and hot flushes.

The ‘not recommended’ technologies and other treatments were:

• cooling mats, cool neck pads and cooling face-mist sprays (not even the expensive ones!) These might make you feel better after having has a hot flush but they aren’t going to change the number or severity.
• paced breathing – taking long, deep breaths to help focus on that rather than the vasomotor symptoms
• acupuncture
• calibration of neural oscillations (this involves wearing bracelet or other device that sends signals to the brain to modify your brain activity which in turn is said to help with vasomotor symptoms
• chiropractic interventions
• cannabinoids.

The ‘not recommended’ medications were:

• pregabalin – this is a change from last time when it was  recommended. Now the panel says the risks outweigh the benefits and the difficulties in accessing it is another factor to consider.
• clonidine – a blood pressure medication that used to be recommended but has slide off the list this time too
• suvorexant – an insomnia treatment.

The ‘not recommended’  supplements were:

Every single one.

No herbal, botanical or any other type of supplement made it onto the recommended list. According to  Dr Chrisandra Shufelt, who was leader of the panel the message is: ‘save your money’ – there is no evidence that any of them make any difference hot flushes and night sweats, no matter what the ads tell you. This includes eating soy foods, soy extracts or soy metabolites such as ‘Equol’.

Some supplements may have good results for 3 months – but that coincides with how long the placebo effect usually lasts, and after that the effectiveness wains. But if you’re happy with your supplements, they’re doing you no harm, are not interacting with any of your other medications and your doctor is happy with what you’re taking, the choice is yours.

The panel concluded “hormone therapy remains the most effective treatment for vasomotor symptoms” but for those who can’t take it or don’t wish to take it, knowing the effectiveness of other treatment options is vital.