The other menopause gap
and the depressing new guidelines on non-hormonal therapies for hot flashes
The North American Menopause Society (NAMS) released a statement this week updating its position on effective non-hormone therapy for hot flashes.
An advisory panel of clinicians and research experts in women’s health were chosen to evaluate the literature published since the last version, in 2015.
The NAMS panel divided the topics into five sections: lifestyle, mind-body techniques, prescription therapies, dietary supplements, acupuncture and other treatments and technologies. The top line? “Hormone therapy remains the most effective treatment for vasomotor symptoms and should be considered in menopausal women within 10 years of their final menstrual periods”.
Much like they did for the hormone therapy position statement published last year, they rated the scientific evidence on Level 1 (good and consistent), Level II (limited or inconsistent) and Level III (consensus and expert opinion). Here’s what they said:
Obviously, this is mostly about the other drugs on the market. Fezolinetant, by the way, is a neurokinin B antagonist I’ve covered before. This class of drugs was originally developed for psychosis and has been repurposed by several companies, with Astellas Pharma’s Veozah the first to be approved by the Food and Drug Administration just last month.
The supplements/herbs studied were: Pollen extract, ammonium succinate, Lactobacillus acidophilus, rhubarb, black cohosh, wild yam, dong quai, evening primrose oil, maca, ginseng, labisia pumila/eurycoma longifolia, chasteberry, milk thistle, omega-3 fatty acids, vitamin E.
My take:
The “not recommended” list is hard to digest. It doesn’t take more than common sense to figure that the things that make us healthy humans would make peri/menopause easier. Most women will tell you that they feel better if they reduce sugar and processed food, avoid triggers (ie stress, alcohol and coffee), and pursue relaxation, exercise and yoga. These behaviors only make us more healthy and resilient against the precursors for disease, which we are more vulnerable to during this time of imbalance. It’s worth a try, won’t harm anyone and it doesn’t even cost anything.
In recommendations like this, lumping “supplements/herbal remedies” together in one category is mind-boggling. That’s like creating a category of “drugs”. It exposes the fundamental gap women face in getting the right care in a polarized system where you have “natural” at one end and “pharmacological” at the other. It takes all of it, and all of it should be carefully considered. But… there are also a lot of heavily marketed garbage supplements, mostly very small studies looking at efficacy, and barely any specifically for peri/menopause. And then there is the mish-mash of potentially worrying ingredients in a not-very-well-regulated industry, not to mention the possibility of low-quality or allergenic excipients (also an issue with pharmaceuticals). Supplements are tricky, and just like drugs, they can be hard on our livers.
We have to reconsider the concept of “evidence”: understanding how it is obtained and conducted, who funds it, and who and what this system favors. It is exceptionally expensive to conduct a randomized controlled clinical trial (RCT), which is considered the gold standard for scientific evidence. I can’t imagine anyone funding a study on how cutting out sugar, processed food or alcohol impacts hot flashes; or on acupuncture. That’s why a lot of the interesting studies come from outside the US. But of course, being less well-funded, they are smaller. It just takes a bit of common sense to see the funnel here: drugs require RCTs to be approved, and the funding of them is done with a commercial end-goal in mind – selling to the consumer – and that is why a level of evidence for them exists. You don’t need an RCT to sell supplements, so no level of evidence required. The bottom line? This review is mostly about drugs, because it is based on a body of evidence, and for that you need drug companies to fund the trials. It’s a frustrating circle.
The last point brings me to the latest Substack on this position statement from The Menopause Manifesto author and ob-gyn Jen Gunter. It’s the headline that gets me: What Nonhormonal Therapies for Hot Flashes Actually Work?
And the “actually work” that I find so depressing. After 30 years in journalism, much of it concentrated in science and health, it’s glaringly obvious that because the research-based system is so rigged, it takes a mix of scientific evidence, expert opinion based on clinical observation and personal experience to answer the question about what does “actually work”. (Hence those are the 3 pillars of Hotflash inc)
For example, when I am upset, anxious and lost, a reiki session with a woman named Vandana sorts me right out. I believe in energy, and she believes in me, and an hour in a room together “actually works” for me. It’s expensive, so I don’t do it unless I really need it. But it’s money well spent when I do. Same for acupuncture. I believe in these things, and many other things, even though no one has paid to study them.
Are they a placebo? I do not care. (How we think about placebos is a topic for another day.)
So where are we, then? As a naturopathic doctor who regularly helps patients with supplements, lifestyle intervention and hormone therapy DM’d me this week: “we deserve so much more research and effort. It’s hard not to feel down about it sometimes”.
Ten years from now things will be completely different. I’m not sure it will be better, but we will know more. All we can do now is spot the narrative and the really messed up aspects of the allopathic system – knowing that it really is, at heart, a clever funnel to prescriptions – and navigate within it and around it. Do our research. Tap into common sense and remind ourselves that herbs, minerals and practices ranging from acupuncture to figuring out what upsets us and dealing with it have been used successfully for centuries.
While the 2022 hormone therapy guidelines from NAMS make sense, and these technically do, they also really don’t. Keeping in mind the inherent limitations on which they sprung from, I’m going to continue using a combination of evidence, experience and expert opinion in this work – and for myself.
When I approach a new thing (and I’ve written about many over the years), I like to ask these questions: Does this help? What is the evidence? Is there a possibility for harm and if so, how much? Can I ease into it to know for sure? Is it sustainable to add into my life, and can I afford to do so? Do I want to become dependent on this thing that I don’t have control over?
And then, the most important: Who profits from me using it? And can I trust them?
Editor’s note
I don’t want to imagine a world without magnesium. That is all.
We are getting closer, yet still so far away. It is a bit maddening when I realize that my road to health has 100% completely come from my tenacious research and guinea-pigging myself. Educating women to their own cycle awareness and trusting their bodies' signals along with their innate intuition(this is not completely lost is it?) is the best that I can do for now. Don't lose heart. As the words of my now deceased grandmother came back to me this past week. Years ago, when I told her what I uncovered about cycle awareness, she said, 'keep going'. Let's keep going for our grandmothers, mothers, daughters and sisters.
It's disheartening to read the Financial Disclosures - thank you for including that in your article. Can anyone be trusted? Learning to trust my own body and my own cycle has been empowering and beneficial; it's wisdom that I'm sharing with my teenage daughter. And despite the recent recommendations, Reiki and yoga work for me. Thank you for pushing forward for all of us!