Margie Minkler started getting hot flashes in her early 40s.
“It feels like a cartoon of somebody who is turning red from their toes up to their forehead, and then bursts out in sweat,” she says. “My face would be red as a tomato.” These hot flashes kept her up at night for years. Her primary care doctor told her she should “grin and bear it” for the next 10 years.
At first, she did just that. But after three years of struggling, she mentioned her hot flashes to her gynecologist, who prescribed a hormone-replacement lotion she could rub on her hips daily.
“Within three days, I kid you not, all my side effects of menopause were gone,” Minkler says.
But, after eight years of using the lotion, she had to stop when her doctor found a lump in her breast. Her doctor worried the hormones in the lotion could raise her risk for breast cancer.
“No one had told me that once you stop using that lotion, you get thrown right back into the middle of menopause!” she says. Her hot flashes came rushing back, but she’s grateful they only lasted another four to six months to the end of her menopausal experience.
For those seeking an answer to hot flashes, the Food and Drug Administration (FDA) approved Veozah (fezolinetant), in May 2023. The non-hormonal drug was tested in people with moderate to severe hot flashes. Moderate hot flashes are defined as those that cause both heat and sweating, but do not prevent you from continuing daily activities. Severe hot flashes are those that cause heat and sweating intense enough to cause you to stop current activities. Any hot flash that causes you to wake up during the night is considered severe.
Minkler says she’s not sure if she’d ask for the drug if she were having hot flashes today.
“I have become a little more resistant to trying drugs without doing a lot of research, but I would be interested in researching that and pursuing it,” she says.
In the clinical trial of Veozah, published in 2023 in The Lancet, participants reported fewer hot flashes within just a week of starting the medicinal therapy. However, trial participants were only tracked for about a year, so we are learning more about the potential side effects of Veozah now that it’s on the market. Researchers typically find new safety risks in about 30 percent of newly-approved drugs within 10 years of their FDA approval.
What Are Hot Flashes?
Hot flashes are the most common complaint women express during the transition to menopause. Menopause is the time in a woman’s life when levels of reproductive hormones, such as estrogen and progesterone, drop, and she gradually stops releasing eggs from her ovaries. During this time, her periods become unpredictable until they stop entirely.
While we typically associate menopause with our reproductive organs, much of the process is actually guided by the brain. Deep in the center of the brain are the hypothalamus and the pituitary gland, both of which sense and react to the levels of hormones already in your body, such as estrogen. When the levels are low, it might signal the ovaries to release more estrogen, for example.
The hypothalamus also controls your body temperature. That’s where the hot flash “trouble” starts.
“The neurons that control our reproduction get huge. They just get massive, like 100 times bigger than they are normally because they are trying so so so hard to release an egg,” explains Susan Reed, M.D., MPH, a professor of obstetrics and gynecology at the University of Washington. Because of this, “they throw off the temperature controlling area of the brain.”
Reed adds that, while most of us think of hot flashes as making us exceptionally warm, people going through menopause often also feel very cold. Then when the body tries to compensate by warming you up, you end up with a hot flash.
“It’s just a dysregulation of the [body’s] temperature, and that’s what the hot flash is,” she says.
The main treatment for hot flashes, prior to Veozah’s approval, has been hormone replacement therapy (HRT), a treatment in which you take estrogen and progesterone to bring your levels closer to where they were before you started the menopausal transition. For several years, scientists were concerned that the hormonal treatment raised women’s risk of heart disease and breast cancer. After years of additional studies and reanalyzing data, scientists are finding that HRT seems to lower the risk of heart disease for many women, and only seems to raise breast cancer risk slightly, depending on factors such as type of HRT used, duration of use, and the age one begins taking it.
There are certain individuals, such as breast cancer patients, for whom HRT is likely not a safe option, and many women are wary of taking hormones even if they don’t fall into a known high-risk population. That leaves a large population with few options for treating hot flashes.
How Veozah Works
Veozah is not a hormonal drug. It binds to a receptor that’s found on the brain cells in your hypothalamus. Receptors function like locks, with specific molecules serving as the keys. When a molecule finds a receptor on a cell that it fits into, it binds to it, sending a message to the cell. These messages tell your cells to start or stop the processes that keep your body functioning smoothly.
Most of the molecules that bind to receptors are made naturally in your body, but some can come from drugs.
When Veozah finds and binds to the right receptors in the brain, it stops the hypothalamus from trying so hard to regulate your body temperature, so you don’t feel such strong swings between cold and hot.
Side Effects of Veozah for Hot Flashes
There are many different types of receptors found on many different cells in your body. The type of receptor that Veozah binds to is called a “neurokinin 3” receptor. They’re found on brain cells in the hypothalamus, but some other cells throughout the body also have these types of receptors.
Since scientists can’t always control exactly where a drug travels in your body, sometimes it finds receptors that it can bind to outside of the brain. For example, one organ that happens to have a lot of neurokinin 3 receptors is the liver. That’s why one potentially dangerous side effect of Veozah is liver damage. When the medication was first FDA approved, it contained a warning that some patients might experience elevated liver enzymes on blood tests, a sign of liver damage.
On September 12, 2024, the FDA updated Veozah’s label to warn of the possibility of liver damage. It also recommends that healthcare providers conduct liver function tests more often than originally recommended. Initially, blood work was recommended every three months for the first nine months. Now, the FDA recommends providers check liver function once a month for the first two months, then transition to testing every three months.
The September 12th warning was added after a case was reported via the FDA Adverse Event Reporting System (FAERS) database. In that instance, the patient had elevated liver enzymes, but after discontinuing the medication, her liver enzymes gradually fell back to normal.
On December 17, 2024, the FDA escalated its initial warning to black box status, the most prominent warning a medication can carry. While the drug’s clinical trials showed that women whose liver enzymes were elevated experienced no symptoms, the label states that after the drug went to market, several women reported liver injury within 40 days of starting the medication. Their liver enzymes became elevated and they experienced symptoms such as fatigue, nausea, itching, jaundice, pale feces, and dark urine. Once the medication was stopped, their symptoms gradually improved.
If you experience symptoms of liver damage such as jaundice (yellowing of the eyes or skin), a swollen abdomen, nausea or itching, you should call your physician immediately to discuss getting off the medication.
Other Side Effects of Veozah
Some less dangerous side effects reported in the clinical trial included:
- Abdominal pain
- Diarrhea
- Insomnia
- Back pain
When Can I Stop Taking Veozah?
Clinical trial participants saw fewer hot flashes within a week of starting Veozah. However, if you stop taking it while you’re still experiencing the menopausal transition, your hot flashes will come back. On average, hot flashes last about seven to eight years, but the actual range for each woman varies widely from around four to 11 years, and over time, they may become less intense.
While those on Veozah may be instructed to stay on it during their entire menopausal transition, it’s important to note that clinical trials for Veozah only lasted about one year. This means patients may find themselves taking a medication for a longer period than it was researched. The longer the drug is on the market, the more we’re likely to learn about the efficacy, risks and side effects of extended use.
When it comes to her personal patients, Dr. Reed recommends that they take a “drug holiday” once a year. She instructs them to stop taking HRT or Veozah, for two weeks before their annual appointment.
“They see how they feel. If they feel horrible, and they are getting hot flashes, and they’re happy on their drugs, they restart them,” she says.
Be sure to talk to your doctor about using a drug holiday as a method for deprescribing. It can be dangerous or cause withdrawal symptoms if done with certain drugs, such as antidepressants. Depending on your personal health history, you and your doctor can work together to create a safe tapering plan for deprescribing purposes.
Questions to Ask Your Doctor About Side Effects of Veozah
As it does with all new drugs, the FDA is continuing to monitor reports about side effects and safety concerns with Veozah. So far, we’ve learned that there is a small but serious risk of liver damage in the first 40 days of use. It’ll be important to ask your healthcare provider how much researchers know about using the treatment for more than a year.
Additionally, you can report any side effects you experience to the FDA to help them monitor and catch adverse effects that may not have appeared in the clinical trial here.
It’s also a good idea to ask about any risks specific to you, such as whether or not other drugs you’ve been prescribed could interact with Veozah and increase your risk of liver damage or other side effects.
How to Ease Hot Flashes Naturally
Both Veozah and HRT are designed to be taken daily to help prevent hot flashes before they happen. But if you do get hot flashes, Dr. Reed says there are many things you can do to lessen their intensity while you’re experiencing them.
“I don’t think we talk about that enough,” she adds.
Some of her suggestions include:
- Placing your hands on a cold desk or taking your shoes off and putting your feet on cold tile. “We emit heat through the soles of our feet and palms of our hands,” she explains. Cooling them quickly can help.
- Using neck fans
- Wearing layers so you can add and remove clothing to adjust your temperature easily.
- Practicing meditative techniques and breathing exercises.
“It helps to not get angry that the hot flash is coming, rather just breathe and be more accepting of it,” notes Dr. Reed.
MedShadow reached out to some of our readers to ask how they managed hot flashes. Here’s what they had to say:
Carol Gee, an author, says that she still gets occasional hot flashes even though she finished menopause 11 years ago. She wears layers and sometimes sleeps without clothing to help keep herself cool.
She adds that she periodically takes black cohosh or Estroven supplements, which can usually be found at the pharmacy or online, but only when she feels she really needs them.
[If you’re considering treating your menopausal symptoms with supplements or over-the-counter medications, it’s important to consult with your healthcare provider first, as these can affect hormone levels if taken without supervision.]
Leslie Shull, a health coach and yoga instructor, credits regular exercise, yoga, prioritizing sleep, and a healthy diet for the fact that her hot flashes don’t seem to be as intense and disruptive as those of her friends. Still, like many women, she recommends dressing in layers, staying hydrated, or carrying around a personal fan when the hot flashes do hit.
Minkler says she used cold towels around her neck and “lots of cold showers.” Other than that, she drank tea and took vitamins she was told would help.
Hot flashes can be deeply uncomfortable, disrupting sleep and quality of life. Be sure to ask your doctor about all the options available to manage them, from cold showers to HRT and Veozah, and review how each one might affect you as an individual.
