Charity Scott, a 51-year-old trauma therapist in Los Angeles, entered menopause in May this year but has been dealing with hot flashes for about a decade.
“I was working with kids as a teacher, and they’d come up to give me a hug and be like, ‘Ew, why are you all wet?’” she recalls. “The cranial/facial sweating is the worst for me. I just looked insane and untrustworthy and nervous.” Though initially wary of hormone therapy because of her family history of aggressive breast cancer, Scott tried it for 6 months. But shortly after breaking her ankle, a “weird pain” in her right calf turned out to be a venous thromboembolism, both a rare risk of hormone therapy and a contraindication to continuing it.
She was able to continue to use a hormonal vaginal cream for vulvovaginal symptoms, but she had few other options for managing hot flashes. She couldn’t tolerate gabapentin’s side effects and couldn’t use selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) because she was already taking one. Though her friends had success with over-the-counter supplements, Scott said her health history and existing slate of medications made her “really wary of supplements because of the lack of oversight.”
So she’s been left with environmental strategies: checking and dressing for the weather, using antiperspirants along her hairline and forehead, keeping antiperspirant wipes and a neck fan with her, wearing a cooling towel like a scarf, using ice rollers on her face, and wearing cotton bra liner pads.
Scott is a perfect candidate for the nonpharmacologic approaches to managing her symptoms recommended in The Menopause Society’s 2023 updated position statement on non–hormone therapy options for managing vasomotor symptoms. Aside from evidence on effective nonhormone pharmacologic treatments — SSRIs/SNRIs, gabapentin, fezolinetant (Veozah), and oxybutynin — it includes the nonpharmacologic treatments with evidence of effectiveness: cognitive-behavioral therapy (CBT), clinical hypnosis, weight loss, and stellate ganglion block.
This article will focus on the first two options because weight loss is difficult, if well understood, and stellate ganglion block is a last-resort treatment that involves anesthesia. Although none of these showed overall effectiveness in alleviating symptoms, all performed better than placebo in studies.
Are physicians and other providers seeing perimenopausal and postmenopausal women aware of these other options? As a therapist, Scott knew to try mindfulness meditation and dialectical behavior therapy skills to address her distress tolerance and to reduce the emotional dysregulation associated with her symptoms. Those strategies and her “radical acceptance approach” do not change the frequency or intensity of her hot flashes, “but it changes my response to it,” she says. But she knew of those strategies because of her own professional training. No medical provider had mentioned any of the effective nonpharmacologic treatments recommended by The Menopause Society to her.
One reason for that may be how few providers in the US are certified in menopause medicine. Interest in menopause is rapidly growing, with membership in The Menopause Society swelling from around 2000 a few years ago to more than 7200 today, according to Stephanie Faubion, MD, director of the Mayo Clinic Women’s Health in Jacksonville, Florida, and medical director of The Menopause Society. But only about 2300 providers in the US have a menopause medicine certification. Primary care providers and ob/gyns therefore need to be aware that women may be seeking options beyond hormone therapy or other medications.
“A lot of times, people are interested in just taking an approach that will be less than what they consider to be invasive or aggressive in favor of something that is more natural, holistic, or gentle,” said Karen Adams, MD, a professor of obstetrics and gynecology at Stanford Medicine and director of the Stanford Program in Menopause and Healthy Aging. “Then there are people who prefer to avoid hormones or who really should not take hormones.”
Those individuals may avoid nonhormonal medications because they cannot tolerate the side effects, like Scott, or other medications are not effective for them. Or, they may have contraindications for nonhormone medications or have concerns about polypharmacy and drug interactions if they take multiple other drugs. Finally, some people may already be using hormone therapy but find it insufficient.
“Even with good pharmacologic management, we sometimes still have 10% or so residual vasomotor symptoms, so they may want to try these things in addition,” Adams said.
That’s the case for Angela Verzal, a 54-year-old office administrative worker in Houston, Texas. First, she tried Effexor XR (venlafaxine) and several supplements — DHEA, diindolylmethane, black cohosh, and ashwagandha — to manage her hot flashes. When those didn’t help, she began hormone therapy. “It did make some noticeable improvement,” Verzal said. “I can wear makeup occasionally now.” But it wasn’t enough, so her doctor increased the dose and added fezolinetant. It’s still not enough.
“My quality of life has been dramatically impacted by these hot flashes,” Verzal said. “I used to be active and outside and social all the time. Now? I work and go home about 90% of the time. These hot flashes are literally holding me hostage.”
Again, though, no medical professional she has spoken to has mentioned CBT or clinical hypnosis, two of the most effective nonpharmacologic treatments.
Menopause clinicians, however, regularly include both of those in discussions with their patients about nonhormone options. “A lot of it comes down to their preference,” said Chrisandra Shufelt, MD, a professor of medicine and associate director of the Women’s Health Research Center at Mayo Clinic in Jacksonville, Florida, and the lead author of The Menopause Society position statement. The challenge is access to CBT and hypnotherapy providers, although the rapid expansion of telemedicine during the pandemic has lifted many of those barriers, she said.
“Not only can it improve the bother related to hot flushes, but it can also improve sleep and mood disturbance,” Adams said. Ideally a woman would seek out a provider with CBT expertise who also understand menopause, but that’s probably a very small segment of providers, Adams said. Fortunately, CBT from any qualified provider as well as self-guided forms of CBT should probably still be effective.
Adams referenced a randomized controlled trial from 2012 in which participants underwent CBT for hot flashes in a group setting or in an individual guided self-help format. CBT in both groups was twice as effective at 6 weeks in reducing how bothersome the hot flashes were, compared with a control group receiving no treatment. Benefits continued, though attenuated, at 26 weeks. Both group and self-directed CBT also reduced the frequency of night sweats and improved women’s mood, quality of life, and emotional and physical functioning.
It is important, however, for women to understand the goal with CBT — to reduce how much vasomotor symptoms interfere with their lives rather than reducing how often they occur.
“It decreases the bother and discomfort, not the incidence,” Adams said. Hypnosis, meanwhile, decreases the discomfort as well as the frequency.
For example, a 2013 clinical trial compared clinical hypnosis and “structured attention control” in 187 postmenopausal women. It found that hypnosis reduced hot flashes by 74% after 3 months, compared with 17% in the comparison group. Objectively measured hot flashes, assessed by skin conductance devices, fell by 57% with hypnosis compared with 10% in controls. Women’s sleep quality, treatment satisfaction, and improvement in interference with daily life were also better in the hypnosis group.
Gary Elkins, PhD, a professor of psychology and neuroscience at Baylor University in Waco, Texas, and the lead author of that paper, has spent much of his career studying the benefits of clinical hypnosis and trying to make it more widely accessible.
Distinct from pop culture images of hypnosis, Elkins describes clinical hypnosis as “a mind-body intervention similar to mindfulness, guided imagery, and relaxation in that they all involve the person sitting quietly with focused attention,” he said. “Then, within that state, the person is more receptive to or better able to respond to suggestions.” He said people vary in their susceptibility to suggestion, so the effectiveness of clinical hypnosis varies by person.
The hypothesized mechanism behind hypnotherapy for vasomotor symptoms relies on the theory that hot flashes are caused by a dysregulation in the thermal regulatory system. “Since core body temperature is regulated by the hypothalamus, when a woman has a hot flash, the brain is perceiving heat, and the hot flash is sweating to cool the woman down,” Elkins said.
“In hypnotherapy, the person enters this deeply focused, relaxed state and receives suggestions or mental images of coolness, such as walking down a mountain path feeling snow on their face or a cool breeze,” something the individual can personally relate to. Essentially, a person learns to trick their brain into perceiving coolness instead of heat. “The idea is, if the brain doesn’t misperceive heat, then no hot flash occurs, and that’s exactly what we find — the frequency of hot flashes begins to decline.”
A review of the evidence presented at the 2024 Menopause Society’s annual meeting compared clinical hypnosis and CBT. The 23 studies identified on either intervention included a dozen randomized controlled trials, with 15 total studies on CBT and eight on hypnotherapy. Hypnotherapy reduced frequency of hot flashes by 63%-80%, including a 41% reduction in hot flashes objectively or physiologically measured with a skin conductance device. Though not as effective as hormone therapy, this effectiveness was similar to that of venlafaxine, paroxetine, and gabapentin. Hypnotherapy also reduced the severity of hot flashes by 50%, and women reported that interference from hot flashes in their daily lives declined by 55%-70%.
The evidence on CBT did not show a consistent drop in subjectively or objectively measured frequency of vasomotor symptoms, but women reported a 10%-59% reduction in daily interference across the studies.
CBT and Hypnotherapy
Until recently, the biggest barrier to CBT and hypnotherapy has been access, whether it’s finding providers who offer this treatment or paying for it, particularly if insurance does not cover it.
But both types of therapy can be provided via telemedicine, and new options for “portable” virtual therapy have emerged. Elkins helped develop the Evia app, which delivers a 5-week self-directed hypnotherapy program. Users can download the app (Apple, Android) to try 1 week free and then choose whether to purchase the full program, which involves listening to a 15-minute hypnotherapy session daily for 5 weeks. So far, researchers have found no adverse effects from using Evia, which is under review for US Food and Drug Administration clearance and continuing to be studied.
Shufelt is working with a team to design a virtual reality delivery system for CBT in a three-dimensional world. “There’s approved forms that are used for pain and in other areas, but there’s really little in the space of menopause,” said Shufelt, who said a clinical trial will begin in 2025. They hope to make the VR program comprehensive, addressing not just vasomotor symptoms but also sleep and sexual health, she said.
Either of these options could be used on its own or in combination with hormone therapy or other medications, Elkins said. “It’s not an either-or,” he said. “It’s giving women an option, another tool, and empowerment.”
Intuitive strategies for reducing hot flashes include cooling techniques with clothing adjustments or cooling products, such as towels and fans, and avoiding triggers. Although alcohol, caffeine, spicy foods, hot foods or liquids, and even hair dryers have all been cited as possible triggers, no clinical trials have assessed the effectiveness of avoiding them.
Furthermore, “by the time [women] seek a menopause provider and are actually in front of you asking about treatment options, they’ve probably already avoided their triggers,” Shufelt said.
Finally, a wide range of herbs and supplements are marketed for vasomotor symptoms, but the evidence is currently too inconsistent or inadequate to recommend them. Limited or inconsistent evidence exists for soy, pollen extract, ammonium succinate (Amberen), and rhubarb. Adams acknowledged the limited evidence for soy but noted there is little harm in adding soy to people’s diets.
Black cohosh, which carries a cautionary statement for risk for hepatoxicity, has been extensively studied, but a meta-analysis of 16 studies found no benefit for vasomotor symptoms. Similarly, small studies have not found benefit for wild yam, dong quai, evening primrose, maca, ginseng, Labisia pumila/Eurycoma longifolia, chasteberry, milk thistle, omega-3 fatty acids, vitamin E, or cannabinoids. Women often do show improvement from using some of these, but it’s similar to that seen with placebo, Shufelt said, “because placebo has a very high rate of relief, especially in hormone therapy trials.” Shufelt noted the lack of regulation for safety and purity in these products as well.
Faubion, Shufelt, and Adams had no disclosures. Elkins developed the Evia app.
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