OBJECTIVE: To create an evidence-based position statement regarding the 
treatment of vasomotor symptoms associated with menopause.
DESIGN: The North American Menopause Society (NAMS) enlisted clinicians and 
researchers acknowledged to be experts in the field of menopause-associated 
vasomotor symptoms to review the evidence obtained from the medical literature 
and develop a document for final approval by the NAMS Board of Trustees.
RESULTS: For mild hot flashes, lifestyle-related strategies such as keeping the 
core body temperature cool, participating in regular exercise, and using paced 
respiration have shown some efficacy without adverse effects. Among 
nonprescription remedies, clinical trial results are insufficient to either 
support or refute efficacy for soy foods and isoflavone supplements (from either 
soy or red clover), black cohosh, or vitamin E; however, no serious side effects 
have been associated with short-term use of these therapies. Single clinical 
trials have found no benefit for dong quai, evening primrose oil, ginseng, a 
Chinese herbal mixture, acupuncture, or magnet therapy. Few data support the 
efficacy of topical progesterone cream; safety concerns should be the same as 
for other progestogen preparations. No clinical trials have been conducted on 
the use of licorice for hot flashes. Among nonhormonal prescription options, the 
antidepressants venlafaxine, paroxetine, and fluoxetine and the anticonvulsant 
gabapentin have demonstrated some efficacy for treating hot flashes and were 
well tolerated. Two antihypertensive agents, clonidine and methyldopa, have 
shown modest efficacy but with a relatively high rate of adverse effects. For 
moderate to severe hot flashes, systemic estrogen therapy, either alone (ET) or 
combined with progestogen (EPT) or in the form of estrogen-progestin oral 
contraceptives, has been shown to significantly reduce hot flash frequency and 
severity. Clinical trials have associated ET/EPT with adverse effects, including 
breast cancer, stroke, and thromboembolism. Several progestogens (both oral and 
intramuscular formulations) have shown efficacy in treating hot flashes, 
including women with a history of breast cancer, although no definitive data are 
available on long-term safety in these women.
CONCLUSIONS: In women who need relief for mild vasomotor symptoms, NAMS 
recommends first considering lifestyle changes, either alone or combined with a 
nonprescription remedy, such as dietary isoflavones, black cohosh, or vitamin E. 
Prescription systemic estrogen-containing products remain the therapeutic 
standard for moderate to severe menopause-related hot flashes. Recommended 
options for women with concerns or contraindications relating to 
estrogen-containing treatments include prescription progestogens, venlafaxine, 
paroxetine, fluoxetine, or gabapentin. Clinicians are advised to enlist women's 
participation in decision making when weighing the benefits, harms, and 
scientific uncertainties of therapeutic options. Regardless of the management 
strategy adopted, treatment should be periodically reassessed as 
menopause-related vasomotor symptoms will abate over time without any 
intervention in most women.