Fezolinetant

Fezolinetant is a tablet licensed to treat moderate to severe hot flushes and night sweats without hormones. The name stays the same in every language.

How it works

The British Menopause Society describes it as an NK3 receptor antagonist. In plain terms, it blocks neurokinin B, a signal in the brain that the BMS links to hot flushes and night sweats. It does not put estrogen back. It works on the signal instead.

Who it is for

NICE's appraisal (TA1143) looked at it for women for whom HRT is unsuitable. It describes four groups: women for whom HRT is ruled out, women whose doctor judges that its risks outweigh its benefits, women who have had to stop HRT, and women who do not want it.

It also sets out what counts as moderate and severe. Moderate means heat with sweating, but you can carry on with what you were doing. Severe means heat with sweating that stops you.

The side effects the Pakistan Menopause Society's table lists are abdominal pain, diarrhoea, trouble sleeping, tiredness and raised liver test results (Table 11).

Liver tests

This is the part to know before you start. NICE's appraisal says rare liver injury has been reported, so liver blood tests are now part of its licence: before treatment, during it, and whenever symptoms suggest the liver is affected. It says fezolinetant is not recommended for people with liver disease. Your doctor will set the timing of the tests.

Who should not take it

The PMS table says to avoid it in cirrhosis and in severe kidney impairment, and flags interactions with some other medicines. Bring a list of everything you take, including anything from the pharmacy counter.

NICE's appraisal notes that women having treatment for breast cancer or other estrogen-dependent cancers are not covered by its licence, because there is no trial data for them. After treatment has finished, any decision is an individual risk assessment.

The guidelines set out an order, and fezolinetant sits in a specific place in it. NICE NG23 recommends offering HRT for hot flushes and night sweats first (1.5.1). For women for whom HRT is unsuitable: "Fezolinetant is recommended as an option for treating moderate to severe vasomotor symptoms associated with menopause when HRT is unsuitable." (1.5.3)

The other options NICE NG23 names include menopause-specific CBT. NICE also says SSRI and SNRI antidepressants, and clonidine, should not routinely be offered first for hot flushes on their own (1.5.4). The full list is on non-hormonal treatments.

In Pakistan, the PMS table names a local brand of fezolinetant (Table 11).

If your flushes stop you mid-task, wreck your sleep, and HRT is off the table or not what you want, that is reason enough to ask about it.

If you are taking it, keep every liver test appointment. NICE's appraisal says liver tests must also be done when symptoms suggest liver damage, so ask your doctor at the start which signs to watch for, and go straight back if you notice any.

NICE's appraisal recorded consultation responses noting that some people choose not to use HRT for reasons of religion (section 3.18). If that is part of your thinking, say so to your doctor; it is a reason they should hear. Whether a medicine is permissible for you is a question for a qualified scholar, and questions about taking it while fasting belong with whoever prescribes it.