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Taming hot flashes without hormones: What works, what doesn't

Some three-quarters of North American women have menopausal hot flashes, but many cannot use hormones for medical reasons or choose not to. Numerous products and techniques are promoted for hot flashes, but do they work, and are they safe? To answer these questions, a North American Menopause Society (NAMS) panel of experts weighed the evidence and made recommendations in a position statement, "Nonhormonal management of menopause-associated vasomotor symptoms," published online in the Society's journal, Menopause.

From 50 to 80 percent of women approaching menopause try nonhormonal therapies for hot flashes. Many don't really work, and sticking with those therapies can just prolong the misery. With little guidance on what does work, many women just experiment with products or suffer. "Many women try one thing after another, and it is months before they stumble upon something that truly works for them," said Janet S. Carpenter, PhD, RN, FAAN.

US surveys show just how uncertain women are about these therapies, with one survey demonstrating that nearly half feel confused about their options for managing menopause symptoms and another showing that 75% don't feel fully informed about herbal products. But with this careful, critical look at all the available studies, healthcare providers can confidently advise women on how to handle hot flashes without hormones.

The NAMS panel found solid evidence that a few therapies do work, including two behavioral approaches and certain nonhormonal prescription medications. Other lifestyle and behavioral approaches, treatments, and a supplement under study look beneficial, but the evidence is not as strong. And the evidence for other lifestyle approaches, herbs, and supplements is insufficient, inconclusive, or just plain negative.

Randomized, double-blind, controlled trials--the gold standard for determining therapies' effectiveness--showed that a cognitive-behavioral therapy approach that combined relaxation techniques, sleep hygiene, and learning to take positive, healthy approaches to menopause challenges was significantly effective in reducing women's ratings of hot flash problems (although not their number). And randomized, controlled trials of clinical hypnosis demonstrated the approach was significantly better than a "structured attention" therapy approach in postmenopausal women with frequent hot flashes and significantly better than no treatment in breast cancer survivors. The panel recommends these two mind-body approaches.

Evidence that isn't as strong suggests that some other approaches may be beneficial, including weight loss, stress reduction, a soy derivative under study (S-equol), and stellate ganglion block (a type of nerve block), so the panel recommends these with caution.

Well-conducted studies show that various nonhormonal prescription medications are helpful, although they may not offer as much relief as hormones. The selective serotonin reuptake inhibitors (SSRIs), including paroxetine, the one FDA-approved nonhormonal therapy for hot flashes, offer mild to moderate improvements. Other medications shown to be helpful include serotonin-norepinephrine reuptake inhibitors (SNRIs, such as venlafaxine), the gabapentinoids (gabapentin and pregabalin), and clonidine. The panel recommends these medications, adding that the lowest dose should be tried first. Then the dose can be increased as patients tolerate it. Choosing which medication to use depends on balancing the benefits and risks for individual patients and on how effective or well tolerated it was if a woman had used it previously.

The evidence is strong that exercise, yoga, paced respiration, and acupuncture do not work for hot flashes, although they may offer other health benefits, so the panel advises providers not to recommend them as hot flash therapy. Studies on over-the-counter and herbal therapies (such as black cohosh, dong quai, evening primrose, flaxseed, maca, omega-3s, pollen extract, and vitamins), relaxation, calibration of neural oscillations (a brain-training technique), and chiropractic intervention show that these therapies are unlikely to help, so the panel advises providers not to recommend them at this time. The panel also advises providers not to recommend stay-cool techniques and avoiding hot flash "triggers" at this time. These approaches are risk-free but don't have studies testing their effectiveness, and sticking with these can just delay appropriate and effective treatment.

"The NAMS panel prepared this position paper to educate health care providers and menopausal women," said Dr. Carpenter. "This information will be critical in maximizing selection of the most effective therapies and minimizing use of therapies that aren't likely to be helpful."

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