New help for hot flashes

photo of a woman sitting up in bed holding the back of her hand to her forehead, drenched in sweat from menopause hot flashes

Do you have your private summers?" In generations past, women knew exactly what this question alluded to: menopausal hot flashes and night sweats far more awful than their alluring "private summers" nickname would suggest.

Yet there's nothing singular about this phenomenon, known medically as vasomotor symptoms. Hot flashes and their nighttime iteration, night sweats, affect an estimated 80% of women and last an average of seven to nine years. For a third, these bursts of intense warmth, sweating, and flushing last more than a decade, according to the Menopause Society.

Hot flashes are also the symptom women in the menopause transition most often talk about and seek treatment for, Harvard experts say. That's why they're hailing a new nonhormonal medication designed specifically for hot flash relief as a game-changing advance.

"Hot flashes are certainly in the top five symptoms women bring up in my office multiple times a day, every day," says Dr. Tara Iyer, who heads the Menopause and Midlife Clinic at Harvard-affiliated Brigham and Women's Hospital. "I see the entire spectrum, ranging from the mild end all the way to women who are debilitated by them and can't get anything done. Some even consider quitting their jobs and going on disability."

Indeed, the workplace toll of vasomotor symptoms only adds to the drag on sleep, mood, and thinking skills. Menopause symptoms cost American women about $1.8 billion each year in lost work time, according to an April 2023 study.

"Getting hot flashes in the middle of an important task can really throw off a woman's concentration," Dr. Iyer says. "You can't really think about anything else but how you're burning up from the inside."

Cracking the code of hot flashes

The first-of-its-kind daily pill, fezolinetant (Veozah), was approved by the FDA in May 2023 for moderate-to-severe vasomotor symptoms from menopause. It works by targeting so-called KNDy (pronounced "candy") neurons — which regulate body temperature — in the brain's hypothalamus. Fezolinetant blocks these nerve cells when dips in estrogen cause them to behave erratically, triggering hot flashes.

The pill performed well in clinical trials, reducing vasomotor symptoms by 60%, says Dr. Jan Shifren, director of the Midlife Women's Health Center at Harvard-affiliated Massachusetts General Hospital.

"The reason this feels like such a game changer — and it's so exciting from a scientific standpoint — is that up until now we had this universal phenomenon going on for millennia and yet we still didn't know why it happened," Dr. Shifren says. "This drug was developed because we've finally figured out the basic biology of hot flashes."

Like nearly every drug, fezolinetant comes with a few caveats. It may cause mild side effects such as belly pain, diarrhea, or insomnia. Additionally, women need to have blood tests to check for liver damage before taking it. The tests are then repeated three more times at three-month intervals.

Fezolinetant is also costly: an estimated $550 for a 30-day supply. Since it's new, insurance coverage may vary. But the medication still represents great progress, Dr. Iyer says. "Frankly, we don't have enough nonhormonal options for hot flashes," she says, "and it's an area in which we've been failing women for a long time."

Hormone therapy alternative

Hormone therapy is still considered the gold standard for treating vasomotor symptoms, since it replenishes diminished estrogen levels and can help control other menopause symptoms as well.

Generally, hormone therapy is considered safe for healthy women under 60 who are within 10 years of their final menstrual period, Harvard experts say. But some women can't take estrogen or don't want to. Those who shouldn't include women who've had breast cancer or certain other cancers, blood clots, heart attack or stroke, unexplained vaginal bleeding, or liver disease.

"For women who choose not to take hormones, have not done well on them in the past, or can't because of a medical reason, this new drug is very exciting," Dr. Iyer says. "The more tools we have in our toolbox, the better."

Lifestyle measures can also turn down the heat

While medications can tamp down hot flashes and night sweats, they're not the only game in town. Certain lifestyle measures can also spell relief.

In newly updated 2023 recommendations on nonhormonal interventions, the Menopause Society pointed to three evidence-backed options. Harvard experts explain why they appear effective.

Weight loss. "Data show that women who are at a healthier body mass index will be less bothered by hot flashes than women who aren't," says Dr. Jan Shifren, director of the Midlife Women's Health Center at Massachusetts General Hospital.

Cognitive behavioral therapy (CBT) and hypnosis. Scientists aren't certain why these mind-body approaches help ease hot flashes, but research shows a consistent benefit from each. "Vasomotor symptoms start in the brain, so it's not surprising that CBT and hypnosis have effects on brain activity," Dr. Shifren says. "We certainly know they can lower our heart rate and stress responses. And they're safe."

Dietary tweaks for hot flash relief aren't backed by science, according to the Menopause Society. But Harvard experts say each woman's own experience counts more. If you've noticed your hot flashes or night sweats flare after a glass of wine, a sugary treat, or a caffeinated drink, avoid that trigger.

"People feel so helpless when hot flashes happen," Dr. Shifren says. "Anything that makes you feel more empowered, regardless of the data, is a good thing."

Other choices

Fezolinetant joins a variety of other nonhormonal medications that have long been prescribed for hot flashes. But there's a key difference: fezolinetant is designed specifically for this use, while the rest are primarily meant to treat other conditions and prescribed off-label to lessen hot flash frequency and severity. They may also lead to troublesome side effects.

In June 2023, the Menopause Society updated its recommendations regarding nonhormonal hot flash remedies for the first time in eight years. In addition to fezolinetant, the group said these three options are also effective:

Selective serotonin reuptake inhibitors (SSRIs). These antidepressants, especially paroxetine (Paxil), have been a mainstay of treatment for women who opt not to take hormone therapy. "They may be effective in reducing hot flashes, but might cause weight gain or sexual dysfunction," Dr. Iyer says. "We may be helping some things and hurting others."

Oxybutynin (Oxytrol), which is typically prescribed for overactive bladder.

Gabapentin (Neurontin, Gralise). This drug is usually prescribed for seizures or nerve pain.

"One side effect is sleepiness, which is a real benefit for women with insomnia," Dr. Shifren says.

Aside from side effects, another possible downside of these nonhormonal drugs is that two or more are often needed to reduce hot flash frequency or severity. "Certainly we have options, but they're far from ideal," Dr. Iyer says. "With a condition such as menopause that can cause 40-plus symptoms, we have to be careful not to provoke new ones or cause some symptoms to be worse."

Seeking help

If you're interested in nonhormonal hot flash relief, Harvard experts offer this guidance.

Be bold. If your vasomotor symptoms are truly disruptive, make sure you tell your clinician and advocate for treatment. "Really, you should be the one to decide if your symptoms are bothersome — the clinician can't decide that for you," Dr. Shifren says.

Consider your other symptoms. Certain medications may seem more appropriate if hot flashes aren't your only issue. "If you're also dealing with symptoms of depression or anxiety, SSRIs could take care of both issues," Dr. Shifren says. "If you've got overactive bladder, oxybutynin could help. And if you're sleep-deprived, gabapentin can make a difference."