The Present and Future of Menopausal Vasomotor Symptoms and Treatment

Review of the current treatments and future perspectives for vasomotor symptoms during menopause.

Vasomotor symptoms (VMS) affect approximately 80% of menopausal women worldwide. Characterized by hot flashes and night sweats, the symptoms range in severity and can affect quality of life. A study in the International Journal of Women’s Health reviewed hormonal and non-hormonal treatments and emerging therapies for VMS in menopausal women.

Hormone Therapy 

• Considerations for Prescribing Hormone Therapy

The standard and most effective treatment, hormone therapy (HT) reduces VMS frequency and severity by approximately 90%. Its benefits typically outweigh its risks for healthy women under 60 years of age and within 10 years of menopause onset. However, more than 80% of American women over 50 years of age have at least one chronic medical condition that impacts their decision-making. Venous thromboembolism risk may be elevated with obesity, which can be limited with lower transdermal doses. Stroke risk is greater in women who start treatment after the age of 60 or use high-dose oral estrogen formulations. 

Contraindications for HT include a history of coronary artery disease, stroke, myocardial infarction, unprovoked venous thromboembolism, or women at high risk for cardiovascular disease. International guidelines support HT in symptomatic menopausal women with consideration of age, time since menopause, and risk factors. 

• Formulations
  Estrogen formulations include oral tablets, transdermal patches, subcutaneous implants, topical lotions, and vaginal rings. Estrogens are paired with a progestogen or a selective estrogen receptor antagonist for women with an intact uterus to prevent the risk of endometrial hyperplasia and cancer. 

• Long-Term Management
  Individualizing treatment with the appropriate dose and duration is recommended. Monitoring for emerging health concerns, using tapered doses, and making attempts at discontinuation are recommended for women nearing 60 to 65 years of age. Longer use of HT can be considered in women older than 65 years who experience persistent VMS impacting their quality of life or for bone density protection.

Non-Hormone Therapies

Non-hormone therapies should be offered to women who have contraindications to HT or want to avoid it.

• Lifestyle Changes
  Exercise, weight loss, and cooling techniques are associated with improved symptoms; however, only limited data is available. 

• Mind–Body Techniques
  Cognitive behavioral therapy has shown effectiveness in reducing VMS severity. Clinical hypnosis has demonstrated a reduction in VMS severity and frequency. 

• Pharmacologic Treatment
  Selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors have significantly improved VMS in various trials. Drugs available for treatment include paroxetine, venlafaxine, citalopram, escitalopram, and desvenlafaxine. Gabapentin and oxybutynin have also demonstrated significant reductions in VMS severity and frequency. 

• Non-Pharmacologic Treatment
  Stellate ganglion block with a local anesthetic may improve VMS. Acupuncture is another potential non-pharmacologic alternative.

New Therapies

Estetrol appears safe in early trials and reduces VMS frequency at a low dose. Its improved safety profile compared to estradiol makes it a promising future treatment option.
Neurokinin-3 receptor antagonists can disrupt the signaling pathway for hot flashes. These are undergoing phase 3 and 4 trials and have shown promising reductions in VMS.

Source

Khan, S. J., Kapoor, E., Faubion, S. S., & Kling, J. M. (2023). Vasomotor Symptoms During Menopause: A Practical Guide on Current Treatments and Future Perspectives. International Journal of Women’s Health, Volume 15, 273–287. https://doi.org/10.2147/ijwh.s365808