Nonhormonal Management of Menopause-associated Vasomotor Symptoms (VMS) Key points from the 2015 Position Statement of The North American Menopause Society North American Menopause Society. Menopause. 2015;22(11). © 2015

Use of nonhormonal therapies is high 50% to 80% of North American women use nonhormonal therapies for VMS at midlife North American Menopause Society. Menopause. 2015;22(11). © 2015

Uncertainty about nonhormonal therapies Most midlife women don’t feel fully informed or have concerns 75% don’t feel fully informed about herbals 64% have concerns or are unsure about herb-drug interactions 61% are not confident about herbal product dosing North American Menopause Society. Menopause. 2015;22(11). © 2015

Uncertainty leads to Use of inappropriate or ineffective therapies Delay in use of effective therapies Underuse of effective therapies North American Menopause Society. Menopause. 2015;22(11). © 2015

Recommend: NonRx Two mind-body therapies have level I evidence showing positive effects Cognitive behavioral therapy (CBT) protocols (MENOS 1 and MENOS 2) Clinical hypnosis: Elkins protocol North American Menopause Society. Menopause. 2015;22(11). © 2015

MENOS 1 and MENOS 2 Protocols included psycho-education, paced breathing, CBT Shown to reduce VMS problem ratings (but not frequency) North American Menopause Society. Menopause. 2015;22(11). © 2015

Elkins protocol In-person hypnotherapy and at-home self-hypnosis practice In postmenopausal women with >50 VMS/wk vs active therapy (structured attention) controls: significantly lower VMS frequency, scores In breast cancer survivors vs no treatment: significantly reduced VMS, improved mood and sleep North American Menopause Society. Menopause. 2015;22(11). © 2015

Recommend: Prescription therapies FDA-approved low-dose paroxetine salt Other SSRIs and SNRIs yielding significant VMS reductions in large RCTs Gabapentin and pregabalin North American Menopause Society. Menopause. 2015;22(11). © 2015

Other SSRIs, SNRIs Large RCTs show significant VMS reductions with Paroxetine Escitalopram Citalopram Venlafaxine Desvenlafaxine North American Menopause Society. Menopause. 2015;22(11). © 2015

Prescription therapies: Choice Depends on Prior effective therapy Patient history Adverse events profile and tolerance of adverse effects Coadministered medications North American Menopause Society. Menopause. 2015;22(11). © 2015

Prescription therapies: Choice (cont’d) Depends on Coexistence of mood disorder VMS more bothersome day or night Medication sensitivity Pharmacogenetic testing Patient preference North American Menopause Society. Menopause. 2015;22(11). © 2015

Prescription therapies: Considerations Start lowest dose first; titrate up to effect, tolerance When stopping, taper therapy over 1-2 wk Re-evaluate carefully and regularly (eg, every 6-12 mo) North American Menopause Society. Menopause. 2015;22(11). © 2015

Recommend with caution Level II evidence suggests these may be beneficial Weight loss Mindfulness-based stress reduction S-equol derivative of soy Stellate ganglion block North American Menopause Society. Menopause. 2015;22(11). © 2015

Do not recommend at this time Over-the-counter supplements Herbal therapies Vitamins Relaxation Calibration of neural oscillations Chiropractic intervention North American Menopause Society. Menopause. 2015;22(11). © 2015

Do not recommend at this time (cont’d) These therapies appear risk free but have no evidence testing effects on VMS Cooling techniques Avoiding “triggers” North American Menopause Society. Menopause. 2015;22(11). © 2015

Do not recommend Level I evidence shows these are unlikely to alleviate VMS, although they may have other health benefits Exercise Yoga Paced respiration Acupuncture North American Menopause Society. Menopause. 2015;22(11). © 2015