NAMS Releases 2023 Position Statement on Nonhormone Therapies

CBT, antidepressants, fezolinetant, and other therapies get the green light…but we have some defense of the “not recommendeds”

By Selene Yeager

The North American Menopause Society (NAMS) just released its 2023 nonhormone therapy position statement, which is an evidence-based review of the most current and available literature on lifestyle, mind-body techniques, prescription therapies, dietary supplements, acupuncture, and other treatments and technologies for the treatment of vasomotor symptoms (VMS, aka hot flashes and night sweats). We’re grateful to see such a much-needed deep dive into all these therapies. Yet, if we’re honest, we here at Feisty Menopause are a bit disappointed.

Not in the review itself. It is deeply researched and scientifically solid, as you’d expect from NAMS. It’s the wording that left us wanting. The panel assessed the most current and available literature to “recommend” or “not recommend” the use of the various therapies based on the level of evidence assigned using the following categories:

• Level I: Good and consistent scientific evidence.
• Level II: Limited or inconsistent scientific evidence.
• Level III: Consensus and expert opinion.

In the end, they conclude that the following therapies are “recommended”: Cognitive-behavioral therapy, clinical hypnosis, selective serotonin reuptake inhibitors (SSRIs)/ serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, fezolinetant (Level I); oxybutynin (Levels I-II); weight loss, stellate ganglion block (Levels II-III).

And the following are “not recommended”: Paced respiration (Level I); supplements/herbal remedies (Levels I-II); cooling techniques, avoiding triggers, exercise, yoga, mindfulness-based intervention, relaxation, suvorexant, soy foods and soy extracts, soy metabolite equol, cannabinoids, acupuncture, calibration of neural oscillations (Level II); chiropractic interventions, clonidine; (Levels I-III); dietary modification and pregabalin (Level III).

There’s a lot to digest there, and you can find the paper in its entirety here. (We'll also cover more of these in depth down the road.) The point of the position statement is to arm healthcare professionals with guidance on what works best (outside of menopausal hormone therapy, which is still the gold standard for women who can take it) for reducing vasomotor symptoms based on current scientific studies. So, a physician knows that antidepressants have good evidence to recommend for treatment, as does the new drug VEOZAH™ (fezolinetant), as well as the other therapies on the recommended list. On the flip side, a physician won’t suggest exercise, avoiding triggers, mindfulness, dietary interventions, etc. as they are “not recommended” for VMS.

But something feels lost in that messaging. Specifically the use of “recommended” and “not recommended”, which for many who just read the abstract or the headlines is all they will see. We run the risk of women seeing advice that they’ve read and maybe taken for years now feeling like there’s been a 180 and that advice is no longer recommended, rather than “there’s some evidence it may have benefit, but we need more hard science to say for sure." 

Take avoiding triggers as an example. As the paper notes: “Women are often told to avoid ‘triggers’ such as alcohol, caffeine, spicy foods, or hot foods or liquids.” They cite a study of more than 4,500 Chinese women that linked alcohol intake to VMS. Other research didn’t find the connection and there are no clinical trials on avoiding triggers for VMS, so it gets a “not recommended” designation. Medical institutions all over the globe include “avoiding triggers” in their recommendations for menopausal women. Sure, it doesn’t merit being a stand-alone prescription, and not everyone has set triggers, but many do, and for them, that self-knowledge is part of their self-care approach to menopausal hot flashes.

Likewise, exercise receives a “not recommended” designation, as does yoga, because in short, the research is mixed and messy. These aren’t easy things to study. What type of exercise? What type of yoga? You can’t really do a double-blind study on either. Exercise especially is 100% good for you, women feel better, and it can help with body composition (and managing weight is on the recommended list). So, even if the research is limited (which isn’t to say non-existent) that it may provide some benefit with hot flashes, it still feels like a miss to stamp it with a “not recommended” label.

Another example is that while cognitive behavioral therapy (CBT) is “recommended,” mindfulness and relaxation are “not recommended." Research, including studies published in Menopause and Climacteric in the past several years, has suggested mindfulness can improve quality of life, mood, and reduce VMS in menopausal women and menopausal women with insomnia. But since these studies and the larger body of research haven’t been honed in on VMS specifically in a clinically rigorous way, mindfulness goes into the “not recommended” column. It feels like a hardline dismissal of something that is largely beneficial. 

There’s also something to be said for the potential cumulative effects of all the “not recommended” therapies here. If a woman is working out, lifting weights (lean body mass is negatively associated with VMS), taking a few moments in her day to practice mindfulness, eating nourishing foods, and limiting common hot-flash triggers like alcohol, she may feel better, sleep better, enjoy improved moods, and may not only have fewer VMS, but also may feel less distressed by them. That feels worth a mention from a healthcare provider who is caring for the whole woman rather than one specific symptom of menopause.

None of this is meant to throw NAMS or this position statement under the bus. It’s certainly important that we know the therapies that have the greatest evidence-based benefits so we can help the up to 80 percent of women who experience VMS during menopause. It’s more of a critique of the branding—of calling lifestyle interventions that we know can help some women “not recommended” because there aren’t enough randomized double-blind placebo control studies to support them…and there may never be. It’s a concern that some of these may now be passed over by physicians who work with menopausal women because they don’t have strong research support for VMS specifically, even though they may help with myriad other menopausal symptoms and quality of life broadly. It’s a defense of those types of therapies that we here at Feisty Menopause do most definitely recommend.