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Treatment of menopause-associated vasomotor symptoms: position statement

of The North American Menopause Society.

Menopause 2004 Jan;11(1):11-33.

SUMMARY: OBJECTIVE To create an evidence-based position statement

regarding the treatment of vasomotor symptoms associated with menopause.DESIGN

The North American Menopause Society (NAMS) enlisted clinicians and researchers

acknowledged to be experts in the field of menopause-associated vasomotor

symptoms to review the evidence obtained from the medical literature and develop

a document for final approval by the NAMS Board of Trustees.RESULTS For mild hot

flashes, lifestyle-related strategies such as keeping the core body temperature

cool, participating in regular exercise, and using paced respiration have shown

some efficacy without adverse effects. Among nonprescription remedies, clinical

trial results are insufficient to either support or refute efficacy for soy

foods and isoflavone supplements (from either soy or red clover), black cohosh,

or vitamin E; however, no serious side effects have been associated with

short-term use of these therapies. Single clinical trials have found no benefit

for dong quai, evening primrose oil, ginseng, a Chinese herbal mixture,

acupuncture, or magnet therapy. Few data support the efficacy of topical

progesterone cream; safety concerns should be the same as for other progestogen

preparations. No clinical trials have been conducted on the use of licorice for

hot flashes. Among nonhormonal prescription options, the antidepressants

venlafaxine, paroxetine, and fluoxetine and the anticonvulsant gabapentin have

demonstrated some efficacy for treating hot flashes and were well tolerated. Two

antihypertensive agents, clonidine and methyldopa, have shown modest efficacy

but with a relatively high rate of adverse effects. For moderate to severe hot

flashes, systemic estrogen therapy, either alone (ET) or combined with

progestogen (EPT) or in the form of estrogen-progestin oral contraceptives, has

been shown to significantly reduce hot flash frequency and severity. Clinical

trials have associated ET/EPT with adverse effects, including breast cancer,

stroke, and thromboembolism. Several progestogens (both oral and intramuscular

formulations) have shown efficacy in treating hot flashes, including women with

a history of breast cancer, although no definitive data are available on

long-term safety in these women.CONCLUSIONS In women who need relief for mild

vasomotor symptoms, NAMS recommends first considering lifestyle changes, either

alone or combined with a nonprescription remedy, such as dietary isoflavones,

black cohosh, or vitamin E. Prescription systemic estrogen-containing products

remain the therapeutic standard for moderate to severe menopause-related hot

flashes. Recommended options for women with concerns or contraindications

relating to estrogen-containing treatments include prescription progestogens,

venlafaxine, paroxetine, fluoxetine, or gabapentin. Clinicians are advised to

enlist women's participation in decision making when weighing the benefits,

harms, and scientific uncertainties of therapeutic options. Regardless of the

management strategy adopted, treatment should be periodically reassessed as

menopause-related vasomotor symptoms will abate over time without any

intervention in most