How would you approach non-hormonal treatment of moderate VMS in a postmenopausal patient?
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Patient profile:
• 58-year-old female.
• Menopausal vasomotor symptoms – moderate to severe hot flashes Medical.
History:
• Menopause onset at age 52; 6 years postmenopausal.
• Reports 7–9 moderate-to-severe hot flashes daily, plus night sweats impacting sleep.
• Non-hormonal therapies (layering, lifestyle changes, and black cohosh supplements) tried with no relief.
• Declined hormone therapy in past due to personal preference and perceived risks.
Relevant comorbidities:
• History of hormone receptor–positive breast cancer (diagnosed at 50, Stage I, treated with lumpectomy and 5 years of tamoxifen; now in remission).
• Mild hepatic steatosis (AST/ALT at upper end of normal, FibroScan not suggestive of advanced fibrosis).
• BMI: 31 kg/m².
• Well-controlled hypertension (on lisinopril).
Current Status:
• Moderate sleep disturbance and fatigue attributed to VMS.
• Hot flashes with sweating and flushing that interfere with work and quality of life.
• Strong desire for non-hormonal option with minimal systemic side effects.
1. What do you recommend for non-hormonal treatment of hot flashes in patients with a history of breast cancer or hormone sensitivity, especially when prior options like SSRIs/SNRIs have been ineffective or declined?
2. In patients with mild hepatic impairment or elevated liver enzymes, what considerations influence your prescribing decisions for newer non-hormonal therapies for vasomotor symptoms?
Key takeaways for effective non-hormonal treatment of VMS
Family Practice
"Veozah would be my first treatment option for this patient. It is non-hormonal. They do recommend checking liver enzymes prior to treatment and then at periodic intervals. Her liver enzymes are the upper limit of normal, but still normal. I would not hesitate to use the medication. So many patients have fatty liver, I do not think that would disqualify this patient from treatment."
Obstetrics and Gynecology
"1. I would recommend Veozah and repeat her liver enzymes in 3 months. If her levels increase, I might switch her to GABA at night or consider an SNRI/SSRI to lessen her hot flashes
2. In patients with elevated LFTs, I might not consider using Veozah as first line and still consider HRT, then SNRISSRI or GABA."
Internal Medicine
"There are other nonhormonal therapies, including clonidine (might help with blood pressure), paroxetine, or gabapentin. Veozah could be considered, but slightly elevated LFTs may limit its use. Certainly yoga, exercise, and weight reduction would be beneficial and help with her obesity, hypertension, and her hepatic steatosis. CPT has also been shown to help. Perhaps her sleep disturbances are also from OSA-consider a sleep study."
Family Practice
"I usually would refer her out in the situation; however, if that was not an option, I would consider trial on gabapentin as it has been shown to improve frequency and severity of vasomotor symptoms during the Peri menopausal state. I would not use Veozah due to possible liver issues."
Family Practice
"1. Before the newer non-hormonal therapies, I would recommend soy and black cohosh as over-the-counter options.
2. Now I am using the newer agents, but as mentioned, they require hepatic monitoring, which is important. Would do this cautiously with monitoring of enzymes as recommended by the manufacturer."
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