If you’re currently going through menopause, there’s a good chance you’ve awakened at night drenched in sweat. Roughly 80 percent of menopausal women have hot flashes—periods of heavy perspiration, flushing, and chills. Symptoms such as hot flashes and night sweats can be highly disruptive and leave you feeling like your body is rebelling.
During the transition from perimenopause to menopause (usually between ages 45 and 55), your body produces less of the hormones, estrogen and progesterone. You’ve officially reached menopause after 12 consecutive months without a menstrual period.
Menopausal symptoms (and their severity) vary by person and can also include vaginal dryness, weight gain (especially belly fat), brain fog, mood swings, low libido, insomnia, heart palpitations, and more. There are a number of treatments available today to help women manage the most common symptoms of hot flashes and night sweats, including hormonal therapies and a new non-hormonal medication.
Hormone replacement therapy: friend or foe?
“Traditionally, hot flashes, night sweats, and vaginal dryness were treated with hormone replacement therapy (HRT), which worked quite well,” said Bruce Pierce, MD, who is board certified in obstetrics and gynecology and is a member of the medical staff at Penn Medicine Princeton Medical Center.
With HRT, patients assigned female at birth are prescribed estrogen and progesterone to replace the naturally occurring hormones that decline during menopause.
HRT comes in pills, patches, creams, gels, and other forms. For a long time, patients were successfully treated with HRT, Pierce explained. Then, a large study that began in the 1990s released data that threw the use of hormone therapy into question and stirred up a decades-long controversy.
The Women's Health Initiative (WHI), a long-term national health study, was originally intended to determine if hormone therapy could help prevent heart disease, breast and colorectal cancer, and osteoporosis in postmenopausal women.
“They never studied hot flashes, vaginal dryness, and other symptoms of menopause,” said Pierce. “In fact, they stopped the study early because in the women who took estrogen and progesterone, they saw a slight—not statistically significant—increased risk of breast cancer, heart attack, blood clots, and stroke.”
Pierce explained the problem with conclusions drawn from this study. First, the study only looked at women after menopause. The study’s age range was 50 to 80 (the average age was 65) and included former smokers at high risk for heart disease.
“These are women past the symptom stage for menopause, which is really ages 45 to 55,” he said. In addition, the risk was only associated with the use of combined hormones—not estrogen alone. Progesterone in HRT is only for people with a uterus. “The women who took estrogen alone—meaning, they had a hysterectomy—showed a decrease in breast cancer risk. This never got any press,” Pierce said.
He also pointed out that while the WHI only looked at one type of estrogen and one type of progesterone, there are multiples kinds of each, which may have been safer.
Regardless, once the media seized on the possible increase in breast cancer for combined HRT, most patients and doctors dropped it as an option. Despite the study’s shortcomings being exposed in recent years, a shadow still lingers over HRT in the minds of many patients.
Pierce said that the WHI study led to a new industry: bioidentical hormone therapy (BHRT).
What are bioidenticals?
Bioidentical hormones are plant-based and made in a lab. They mimic the estrogen and progesterone made by your body. Like HRT, BHRT comes in many forms.
Pierce said BHRT is often touted as safer than HRT; however, not all bioidenticals are equal. Some bioidentical hormones are made by drug companies and have approval from the U.S. Food and Drug Administration (FDA). Others are compounded (mixed) by a pharmacist and fall outside FDA regulation, which means they have not been studied for safety, efficacy, and purity.
[H2] A new hormone-free option
In May 2023, the FDA approved a non-hormonal medication that treats the vasomotor symptoms of menopause: hot flashes and night sweats. It has no effect on vaginal dryness.
The medication is classified as a neurokinin 3 (NK3) receptor agonist. It works by targeting and blocking the NK3 receptors in the brain that regulate body temperature. Declining estrogen levels affect these receptors in menopause.
Because this treatment is non-hormonal, it offers an option for patients who can’t take HRT because of a history of breast cancer (particularly hormone-sensitive cancers), vaginal bleeding, stroke, heart attack, or blood clots.
The treatment is not a safe option for patients with kidney or liver disease, because it can elevate your liver enzymes. “They’re recommending that if you prescribe it, you should check blood work first and then maybe every six months,” Pierce said.
Regarding effectiveness, the treatment improved hot flashes in 48 percent of those taking a higher dose and 36 percent of those on a lower dose. The latter was just slightly higher than the 33 percent who reported improvements after taking a placebo.
Compared to HRT, which relieves hot flashes in more than 90 percent of those who take it, this non-hormonal option may not seem like a better alternative. But for those who aren’t candidates for HRT, or are hesitant to try it, the new medication can provide welcome relief.
Other ways to manage menopause symptoms
Pierce often prescribes birth control pills to patients (nonsmokers only) in perimenopause—the phase that usually begins in a person’s mid to late forties. “Just like postmenopausal hormone replacement therapy, birth control pills use estrogen and progesterone to relieve symptoms,” he said.
The hormones in birth control pills will not delay menopause, but they can mask the start of it by artificially inducing a monthly period. Pierce said he prefers to prescribe HRT and birth control pills for symptom relief at the lowest necessary dose, for the shortest amount of time—just to help his patients get through the transition.
Some people turn to herbal supplements or try off-label medications—drugs that are usually prescribed for other conditions but may reduce vasomotor symptoms.
Lifestyle changes can also make a difference, such as regular exercise; a healthy diet; moderating your intake of spicy foods, alcohol and caffeine; wearing lightweight, moisture-wicking clothes; and sipping cold water throughout the day.
“Don't be sedentary and don’t smoke,” Pierce said. “Otherwise, I’m a fan of moderation.”
Pierce also believes HRT can be an effective part of menopause management when used “the way it’s supposed to be, which is for symptom relief for a short period of time.”