NAMS: Nonhormone Therapy Position Statement 2023

SUMMARY:

An advisory panel was selected to review current literature regarding nonhormone therapy based on levels of evidence. In the treatment of vasomotor symptoms in women within ten years of menopause and who are not candidates for or who decline hormone therapy, evidence-based nonhormone options such as behavioral therapies, medications such as SSRIs or gabapentin, and weight loss should be discussed and considered.  

Vasomotor Post Menopausal Symptoms  

• Vasomotor symptoms (VMS) 
  • Defined as hot flashes and night sweats  
• Incidence 
  • Mean 7 to 10 years 
  • 30% >10 years 
• Standard Management 
  • Hormone therapy 
  • First line recommended treatment 
  • Underutilized therapy 
• Contraindications 
  • Estrogen sensitive tumors 
  • Coronary artery disease/myocardial infarction history 
  • Stroke 
  • Venous thromboembolism 

Recommended Nonhormone Techniques and Therapies  

• Mind-Body Techniques 
  • Clinical hypnosis 
  • Cognitive behavior therapy 
• Prescription Medications 
  • SSRIs and SNRIs demonstrate mild to moderate improvement 
    • Ecitalopram 10 to 20 mgs/day 
    • Paroxetine salt 7.5 mg/day 
    • Paroxetine 10 to 25 mg/day 
    • Citalopram 10 to 20 mg/day 
    • Desvenlafaxine 100 to 150 mg/day (start at 25 to 50 mg/day) 
    • Venlafaxine 37.5 to 150 mg/day (start at 37.5 mg/day) 
  • Gabapentin 
    • 900 to 2400 mg/day in divided doses (start with 100 to 300 mg at night, add 300 mg at night, then an AM dose of 300 mg) 
  • Fezolinetant 
    • Neurokinin B antagonist 
    • 45 mg/day 
  • Oxybutynin 
    • 2.5 to 5.0 mg twice daily or 15 mg extended release daily 
    • Long term use may be associated with cognitive decline in older adults 
• Weight loss 

NOT Recommended 

• Yoga | Diet | Cooling techniques | Weight loss | Relaxation techniques  
• All dietary supplements/cannabinoids 
• Acupuncture 
• Chiropractic manipulations 
• Stellate ganglion block may alleviate moderate to severe VMS but is associated with risk of transient seizures or bleeding 
• Medical therapies not recommended 
  • Pregabalin 
  • Clonidine 
  • Suvorexant  

KEY POINTS: 

• Vasomotor symptoms occur in up to 80% of postmenopausal women 
• Mean duration 7 to 9 years 
  • >10 years for one third of women 
• Hormone therapy is underutilized in symptomatic women 
• Hormone therapy is the most effective treatment for vasomotor sympytoms and is indicated for  
  • Women younger than age <60 years 
  • Are within 10 years of menopause 
  • Are without contraindications including 
    • Estrogen sensitive malignancies 
    • Coronary artery disease/myocardial infarction 
    • Thromboembolism/stroke 
      • Inherited high risk for thromboembolic disease. 
• Recommended nonhormone therapies: Prescription 
  • SSRIs/SNRIs 
  • Gabapentin 
  • Oxybutynin 
  • Fezolinetant 
• Recommended therapies: Nonprescription 
  • Cognitive based therapy 
  • Clinical hypnosis 
  • Weight loss 
  • Stellate ganglion block 
• Not recommended or insufficient evidence  
  • Supplements or herbal remedies 
    • Soy extracts 
  • Yoga and exercise 
  • Cooling techniques 
  • Cannabinoids 
  • Acupuncture 
  • Chiropractic interventions 

Learn More – Primary Sources: (Level 3) 

The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society