From OTC meds to unexpected Rx side effects, here are 3 major menopause treatment blind spots—and how to address them
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These new results suggest that a diet change should be considered as a first-line treatment for troublesome vasomotor symptoms, including night sweats and hot flashes.
—Neal Barnard, MD, lead researcher, commenting on the WAVS trial
Menopause management remains an area where clinical knowledge and patient expectations tend to diverge.
A recent MDLinx survey identified several persistent gaps in clinicians’ menopause care knowledge: Nearly two-thirds (64%) of respondents overlooked the limited evidence base for commonly used OTC therapies for vasomotor symptoms (VMS); and almost one-third (31%) failed to recognize important adverse-effect profiles associated with nonhormonal pharmacologic options such as SSRIs and SNRIs.
Below are three blind spots you can close at the point of care.
Related: More than 50% of OB/GYNs don't know these facts about the latest nonhormonal VMS drug—do you?OTC therapies: Widely used, weakly supported?
Despite heavy marketing and patient demand for “natural” or non-prescription treatments, most OTC supplements are not supported by high-quality evidence.
One of the most widely studied OTC therapies is "black cohosh."
Black cohosh
Black cohosh has been studied extensively, yet findings remain inconsistent.[] A 12-week randomized controlled trial of 304 postmenopausal women suggested modest improvement in symptom scores, particularly in those early in the menopausal transition.[]
However, other studies, including multiple trials in breast cancer survivors (N=132 and N=85), often receiving tamoxifen, have shown no benefit over placebo.[]
Safety concerns further complicate its use: gastrointestinal upset, arrhythmia, weight gain, and rare but documented hepatotoxicity have all been reported.[]
In Europe, regulatory bodies now require liver-injury warnings, and the BMS advises explicitly against its use in patients on tamoxifen due to potential drug interactions.[] Any benefit appears modest and population dependent, and the risk profile mandates caution.
Patients on black cohosh should be counseled on cautious use and vigilance for liver symptoms.[]
“Currently, there is insufficient evidence to recommend black cohosh for menopausal symptoms,” says Jen Gunter, MD, an OB/GYN and pain medicine physician.
Isoflavones and soya products (including red clover)
Soy isoflavones show modest, statistically significant VMS relief in several higher-quality analyses and RCTs.
A meta-analysis of randomized trials (median ~54 mg/day for 6 weeks to 12 months) found hot-flash frequency fell about 20% more than with placebo, and severity about 26% more vs placebo.[]
Benefits may be greater when metabolism yields equol: A meta-analysis found S-equol supplementation significantly lowered hot-flash scores, including in equol non-producers given S-equol.[]
More recently, the WAVS randomized trial tested a low-fat, plant-based diet with daily soybeans in postmenopausal women with ≥2 moderate-to-severe hot flashes/day and found it reduced total hot flashes by ~79% at 12 weeks vs ~49% with the usual diet (P < 0.001).[]
These new results suggest that a diet change should be considered as a first-line treatment for troublesome vasomotor symptoms, including night sweats and hot flashes.
—Neal Barnard, MD, lead researcher, commenting on the WAVS trial
However, because of their estrogenic activity, soybeans are not recommended for women with a history of breast cancer.[][]
Psychological interventions
Non-Rx options such as psychological interventions are obviously not available over-the-counter, but they do help. These include cognitive behavioral therapy for menopause (CBT-M) and clinical hypnosis. CBT has been shown to reduce VMS frequency in MENOS 1 and MENOS 2 trials.[]
“Cognitive behavioural therapies are brief, effective, non-medical treatment options for menopausal women that can be delivered by trained health professionals,” says Prof. Myra Hunter, King’s College London, co-author of the MENOS 1 and MENOS 2 trials.[]
Side effects temper nonhormonal pharmacotherapy’s efficacy
Among prescription alternatives, SSRIs and SNRIs (including paroxetine, citalopram/escitalopram, venlafaxine, and desvenlafaxine) remain widely used.[] They produce mild to moderate symptom reductions, often evident within 2 weeks.
Yet the side-effect profile of certain prescription drugs is not trivial. Nausea, constipation, dry mouth, insomnia or somnolence, appetite changes, and sexual dysfunction are all common, with many adverse effects being dose-related. For some patients, these risks outweigh the modest efficacy.
Fezolinetant (NK3R antagonist) is the first-in-class, nonhormonal option that targets the KNDy pathway rather than serotonergic mechanisms. Unlike with SSRI/SNRsI, there is no risk of sexual side effects. Common AEs include abdominal pain, diarrhea, and insomnia.[] However, the drug requires liver monitoring.[]
In December 2024, the FDA added a boxed warning for fezolinetant about serious liver injury and advised monitoring consisting of baseline hepatic labs, monthly labs for the first 3 months, and then at months 6 and 9. The drug should be discontinued if signs/symptoms or significant lab elevations occur.[]
For tamoxifen users or patients who experienced SSRI/SNRI AEs, fezolinetant is a reasonable alternative if they can adhere to LFT monitoring.
Ethnic disparities in symptom burden
The SWAN analysis and subsequent reports consistently report higher prevalence, frequency, and duration of VMS in Black women vs White and some Asian groups, even after adjustment for confounders.[] Median VMS duration across cohorts is ~7 years,[] but is approximately 10 years for many Black women according to SWAN.
Why it matters clinically? If clinicians underestimate VMS burden in Black and some Hispanic patients, they may undertreat, attribute symptoms to other causes, or delay escalation from ineffective OTCs. Proactive discussion, normalizing long durations, and early offering of effective therapies (HT when eligible; or nonhormonal options above) can reduce disparities.
Read Next: You know VMS is underdiagnosed. But are you part of the problem?