Dehydroepiandrosterone (DHEA)/prasterone
DHEA, an androgen precursor to testosterone and estrogen, is approved for the treatment of postmenopausal dyspareunia due to vulvovaginal atrophy based on a placebo-controlled 12-week trial.[92]Labrie F, Archer DF, Koltun W, et al. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2016 Mar;23(3):243-56.
http://www.ncbi.nlm.nih.gov/pubmed/26731686?tool=bestpractice.com
A review of 18 trials concluded that DHEA may slightly improve sexual function compared with placebo.[93]Scheffers CS, Armstrong S, Cantineau AE, et al. Dehydroepiandrosterone for women in the peri- or postmenopausal phase. Cochrane Database Syst Rev. 2015 Jan 22;1:CD011066.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011066.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/25879093?tool=bestpractice.com
However, it is associated with androgenic side effects, mainly acne, and its role remains uncertain.[93]Scheffers CS, Armstrong S, Cantineau AE, et al. Dehydroepiandrosterone for women in the peri- or postmenopausal phase. Cochrane Database Syst Rev. 2015 Jan 22;1:CD011066.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011066.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/25879093?tool=bestpractice.com
Stellate ganglion block
Stellate ganglion block, typically employed in the management of pain syndromes and vascular insufficiency, may be effective in the management of hot flashes in women who cannot take estrogen-based therapy.[94]Kontos M, Agbaje OF, Rymer J, et al. What can be done about hot flushes after treatment for breast cancer? Climacteric. 2010 Feb;13(1):4-21.
http://www.tandfonline.com/doi/full/10.3109/13697130903291058
http://www.ncbi.nlm.nih.gov/pubmed/20067430?tool=bestpractice.com
Further research is required.[95]Walega DR, Rubin LH, Banuvar S, et al. Effects of stellate ganglion block on vasomotor symptoms: findings from a randomized controlled clinical trial in postmenopausal women. Menopause. 2014 Aug;21(8):807-14.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110158
http://www.ncbi.nlm.nih.gov/pubmed/24496086?tool=bestpractice.com
Tibolone
Tibolone is a steroid derived from yams that has mixed estrogen-, progesterone-, and testosterone-like effects on multiple tissues. One Cochrane review concluded that tibolone is more effective than placebo, but less effective than hormone therapy, at reducing vasomotor symptoms.[96]Formoso G, Perrone E, Maltoni S, et al. Short-term and long-term effects of tibolone in postmenopausal women. Cochrane Database Syst Rev. 2016 Oct 12;(10):CD008536.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008536.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/27733017?tool=bestpractice.com
It is not recommended in women with a history of breast cancer, and may increase the risk of stroke in older women.[36]Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015 Nov;100(11):3975-4011.
https://academic.oup.com/jcem/article/100/11/3975/2836060
http://www.ncbi.nlm.nih.gov/pubmed/26444994?tool=bestpractice.com
[97]Cummings SR, Ettinger B, Delmas PD, et al. The effects of tibolone in older postmenopausal women. N Engl J Med. 2008 Aug 14;359(7):697-708.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684062
http://www.ncbi.nlm.nih.gov/pubmed/18703472?tool=bestpractice.com
Tibolone is available in Europe, but not the US.
Fezolinetant
Fezolinetant is a neurokinin 3 (NK3) receptor antagonist. The NK3 receptor has a role in the brain’s regulation of body temperature. The drug is approved by the US Food and Drug Administration and the European Medicines Agency for the treatment of moderate-to-severe vasomotor symptoms (hot flushes) associated with menopause.