Beyond Hormones: Non-Hormonal Approaches to Menopause

Not a Candidate for Hormone Therapy? You Still Have Options for Menopause

Menopause has finally become something people talk about. Hot flashes, hormone therapy, and the old Women's Health Initiative headlines are showing up in the news, on social media, and hopefully in your conversations with friends.

A lot of that coverage argues that women who could benefit from hormone therapy are too often denied it. While that is a valid point, not everyone wants hormone therapy, and not everyone can safely take it. Even for women who use it, it works best alongside other changes.

Below are some non-hormonal options, both lifestyle changes and prescriptions, for three of the biggest health concerns around menopause.

Hot flashes and night sweats

Hot flashes are what most people picture when they think of menopause. Estrogen is still the most effective treatment, but there are other things that help.

Everyday changes that can make a difference:

• Dressing in layers, keeping your home and office cooler, and using a fan
• Drinking less alcohol
• Staying active and building or keeping muscle
• Managing stress

Two non-drug therapies, clinical hypnosis and cognitive behavioral therapy (CBT), also have good evidence behind them.

Prescription options without hormones:

• Low-dose paroxetine. At a dose lower than the one used for depression, this antidepressant is FDA-approved for hot flashes.
• Fezolinetant (Veozah) and elinzanetant (Lynkuet). These newer medications act on the part of the brain that controls body temperature. Fezolinetant requires periodic blood tests to check your liver. Because neither one is a hormone, they're often considered for women who can't take estrogen, including some women with a history of breast cancer. If that's you, talk it through with your oncologist.
• Gabapentin and oxybutynin. Neither is FDA-approved for hot flashes, but both have some evidence that they help and are sometimes prescribed for it.

Bone health

Osteoporosis means bones have become thin and weak enough to break easily. It's a major cause of injury and disability as we age, and women get it more often than men, partly because estrogen drops after menopause.

Hormones aren't the whole story, though. Age, low body weight, family history, smoking, and some medical conditions and medications all raise your risk. You can't feel your bones thinning, so it's easy to miss until something breaks. A bone density scan is how we evaluate for bone health.

Estrogen helps prevent bone loss after menopause, but it isn't FDA-approved to treat osteoporosis once you have it. The basics apply to everyone, at any age: get enough calcium and vitamin D, and do regular weight-bearing and strength exercise.

If you are a candidate for medication, there are several good options:

• Bisphosphonates (such as alendronate, a weekly pill, or zoledronic acid, a once-a-year IV) have been the standard treatment for decades, and millions of people have taken them safely.
• Denosumab is a shot given every six months.
• Bone-building medications (teriparatide, abaloparatide, and romosozumab) can help rebuild bone in people at high risk of fracture.

Your IFM provider can help you calculate your fracture risk, and help manage or collaborate with an endocrinologist or rheumatologist. 

Heart health and metabolism

Heart disease is still the leading cause of death for women in the United States. After menopause, LDL ("bad") cholesterol tends to rise, and the body handles sugar less efficiently, even in women who were healthy before.

Hormone therapy isn't recommended as a way to prevent heart disease. The things that protect your heart are mostly within your control:

• Don't smoke. Quitting is the single most important step. Women who smoke have roughly two to six times the risk of a heart attack.
• Move regularly. Exercise improves blood pressure, blood sugar, cholesterol, and body composition. Short walks count. The usual goal is about 150 minutes a week, and you can build up to it.
• Eat more plants. Aim for at least four cups of fruits and vegetables a day, and keep saturated fat and salt down.
• Sleep well and know your numbers. That means blood pressure, cholesterol, and blood sugar. When lifestyle changes aren't enough, medication can help.

The bottom line

The habits that help you live longer also help with the changes menopause brings. Hormone therapy can help, but it's one option among many. If you can't take it or don't want to use hormone therapy, you still have choices. 

If you have questions about how any of this applies to you or someone you love, schedule a visit with your provider. We'll work through your options together and connect you with a specialist if you need one.