A woman in her fifties, recently came to see me for help with her debilitating hot flashes and night sweats. I read through her chart before walking into the room. Everything seemed straight forward. She had no medical problems, didn’t take any medications, and wasn’t a smoker. I noticed her mother had been diagnosed with breast cancer in her early seventies, but it was isolated and no one else in her large family had ever had a cancer diagnosis. I walked into the room with confidence. This is easy, I thought to myself as I walked into the exam room. I’ve practically healed her already! In my mind, she was an excellent candidate for hormone replacement therapy.
Experience has taught me that rarely is the practice of medicine this easy. I should know better than to assume anything is “easy” and this patient was no different. Although I did not think that her mother’s breast cancer diagnosis was a reason to avoid hormone replacement therapy, this tearful patient certainly did. My seemingly slam dunk was, in fact, an air ball. She quickly rattled off everything she’d been doing: black cohosh, chasteberry (common “CAMS,” which I will explain below), regular exercise, and even cutting back on caffeine and alcohol. The more she shared, the more frustrated she became. She explained that the frequent hot flashes during the day ruined her silk blouses and hair styles. She’d reverted to wearing wigs which made her even hotter. She had hot flashes at work, sometimes while leading high-powered group discussions with mostly male colleagues, which left her feeling distracted and embarrassed. It didn’t stop there. Her sleep was disrupted at night due to sweats. Through tears of frustration, she asked for help reclaiming her quality of life without hormone replacement.
In this instance, the patient had strong personal preferences against hormone replacement therapy, but there are many reasons why someone might not use hormone therapy to manage menopausal symptoms. So you may be asking, what works besides hormones? For this patient, I saw that anxiety about her vasomotor symptoms (hot flashes, night sweats) was just as troubling as the actual symptoms. Since she was already adhering to a healthy diet and a regular exercise routine, I focused on treatment options geared to decrease both her anxiety and hot flashes. In her case, starting an antidepressant known to help with hot flashes improved her symptoms. In addition, cognitive behavioral therapy (CBT) was extremely beneficial in easing her hot flashes and anxiety. At her 6-week follow-up visit, she expressed gratitude that she was feeling like her old self.
Are there other options? Sure! There are many non-hormonal options for treating hot flashes and night sweats, including prescription medications and a wide array of Complementary Alternative Medicine (CAM) modalities.
The prescription options include medicines typically thought of as treatment for depression, seizures, and blood pressure management. Everything from vitamins to herbal supplements to acupuncture to yoga to energy-healing falls under the CAM umbrella–for a more comprehensive description of the CAM modalities, see the National Center for Complementary and Alternative Medicine.
While I’m not going to review every CAM treatment option, I’m going to give you an overview of what the experts agree on in terms of what works (and what doesn’t!) and what the research shows. When it comes to treating the symptoms of menopause, The North American Menopause Society (NAMS) is the world leader in providing up-to-date, reliable and cutting edge recommendations on menopausal care. In 2015, NAMS released recommendations for non-hormonal treatment options. So what were the main recommendations? Drumroll please…
Cognitive Behavioral Therapy and some non-hormonal prescription medicines have been shown in studies to improve vasomotor symptoms. These treatments were given a Level 1 recommendation (which is basically the Grammy of medicine). Prescription medications shown to be effective in treating vasomotor symptoms, include SSRIs (typically used to treat depression and anxiety), clonidine (a blood pressure medication) and gabapentin (often used to manage seizures). All treatments carry side effects and these treatments are not right for everyone. If you’re interested in any of these prescription medicine treatments, follow up with your healthcare provider.
As with most prescription medications, they work even work better when combined with a healthy lifestyle (more on lifestyle changes below) or CBT. CBT is a form of therapy that has been shown to help women dealing with bothersome hot flashes, night sweats, anxiety/stress, depressed mood and insomnia through coping skills and practical strategies. Structured sessions with a licensed therapist or mental health professional trained in this technique help women develop these skills. There are also online resources for women who don’t want or aren’t able to see a mental health professional.
There are a host of therapies that look like they may work to help with vasomotor symptoms, but more studies are needed. These therapies were given a Level 2 recommendation. These included: weight loss, mindfulness-based stress reduction , soy isoflavone supplements containing S-equol derivatives and stellate ganglion blocks. Despite all having tongue-twisting names, each of these treatments is quite different. I’d recommend following the hyperlinks to learn more and see if they might be a good option for you. You can bring these resources (yes, even this blog) to your doctor’s office to talk through best options.
In clinical trials, a number of CAM modalities have not been shown to be better than a placebo in treatment of vasomotor symptoms, so they were put in the “do not recommend” category. This includes over-the-counter supplements, herbal therapies, relaxation techniques, calibration of neural oscillations, exercise, acupuncture and chiropractic interventions. Of course, we love relaxation, exercise and acupuncture for other reasons, but they haven’t been shown to be better than placebo specifically for treating hot flashes due to menopause.
Ok… but what does it really mean to not have shown benefit over placebo? It means that researchers gave half the women in a study the treatment, for example an herbal supplement, and the other half a pill that looked just like it but contained no active ingredients, and the results were the same. That being said, I have a number of patients who tell me herbal remedies really help to reduce their hot flashes, help them sleep, improve their libido, or simply make them feel better. Whether this is due to a placebo effect or these treatments “really work,” I’m not sure. In my opinion, the number of women who endorse the use of herbal supplements count for something. More importantly, many women feel that these interventions help reduce stress, boost energy and improve overall health. Unless someone has a contraindication to herbal supplements – for example, they interfere with a prescription medication – I personally don’t have a concern with my patients giving them a try. As with all medications, there may be associated risks. Herbal medications and supplements can interact with any treatments you’re taking and, since they are not regulated like drugs, it is hard to know what exactly is in them. Speak with your physician and your pharmacist (to check for drug interactions) before you start any herbal treatments. We have also listed a few articles below that explain the potential risks of herbal supplements in more detail.
If you’ve been following all of the blogs, you’ve probably figured out that there is not an exact science to managing menopausal symptoms. In fact, I’ve found that women who have the most benefit embrace a holistic treatment strategy. Medication—whether hormonal, non-hormonal prescription or one of the herbal treatments—works best when combined with a healthy life style. This includes maintaining a healthy diet, managing stress and exercising regularly. Your preferences, symptoms, and medical history should guide medical decisions and will need to be re-evaluated frequently.
Always ask your doctor or other healthcare professional about treatment options that might be right for you. Finding a trusted healthcare professional who is knowledgeable about menopause and encourages shared decision-making is key. Have a story about treating your own menopause symptoms? We would love to hear it! Tweet us at @WomanLab or send us an email at firstname.lastname@example.org.
Carpenter, J. et al. (2015). “Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society.” Menopause 22(11): 1155-1172
More on herbal and dietary supplements:
Qato DM et al. (2016). “Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011”. JAMA Intern Med. Apr;176(4):473–82.
The Lancet Gastroenterology & Hepatology. (2018) “Herbal assault: liver toxicity of herbal and dietary supplements.” The Lancet Gastroenterology & Hepatology. ;3(3):141.
Edited by Leilani Douglas
Photo by Clem Onojeghuo via Unsplash