Veozah (Fezolinetant) in Your 60s and Beyond: What Women Need to Know

What Is Veozah and Why Does It Matter After 60?

Veozah (fezolinetant) is the first non-hormonal, neurokinin-3 (NK3) receptor antagonist approved specifically to treat moderate-to-severe vasomotor symptoms (VMS) of menopause. For women in their 60s and beyond, that distinction matters more than it might at 51. By your 60s, you are typically well past your final menstrual period, and the decision about hormone therapy (HT) has often already been made, sometimes ruled out by a clinician or by your own preference, because of cardiovascular history, prior breast cancer, or simply a preference to avoid hormones altogether.

Hot flashes do not reliably stop at 60. The Study of Women's Health Across the Nation (SWAN) found that median VMS duration is 7.4 years from onset, with women who entered perimenopause with frequent hot flashes experiencing symptoms well into their late 50s and 60s. A meaningful subset of women report symptoms into their 70s.

Fezolinetant works by blocking the neurokinin B (NKB) signaling pathway in the hypothalamic thermoregulatory center. During menopause, the loss of estrogen feedback causes KNDy neurons (kisspeptin, NKB, dynorphin) in the arcuate nucleus to become hyperactive. This NKB hyperactivity drives the downstream activation of warm-sensitive neurons that trigger vasodilation and sweating, producing the classic hot flash. Because fezolinetant targets a neuronal receptor rather than estrogen receptors, it does not carry estrogen-related risks.

How Your Hormonal Status at 60+ Shapes This

At 60 and beyond, your ovarian estradiol production is essentially negligible, typically below 20 pg/mL. Follicle-stimulating hormone (FSH) is persistently elevated, often above 30 IU/L. The KNDy neuron hyperactivity that started in perimenopause may still be present years later, explaining why VMS persists. Fezolinetant addresses that neuronal overactivity directly, without needing to replace the estrogen that is gone.

Thyroid function also deserves attention at this life stage. Subclinical hypothyroidism affects up to 10-15% of women over 60, and its symptoms, including flushing and sweating, can mimic or amplify VMS. Before attributing all flushing to menopause, your clinician should confirm TSH is in the normal range.

What the Evidence Shows

The SKYLIGHT 2 trial, a 52-week phase 3 randomized controlled trial published in JAMA in 2023, enrolled 501 postmenopausal women aged 40 to 65 with at least seven moderate-to-severe hot flashes per day. At week 12, women taking fezolinetant 45 mg once daily experienced approximately 1.9 fewer hot flashes per day than those on placebo in the overall trial, though in the more symptomatic subgroup the absolute reduction was closer to 4-5 per day. At week 52, the reduction was maintained, with no evidence of tachyphylaxis. The trial also measured sleep disturbance using the PROMIS Sleep Disturbance Short Form; fezolinetant produced statistically significant improvements versus placebo.

A separate analysis of the SKYLIGHT program showed that women aged 60 to 65 had response rates comparable to the overall population, with no dose adjustment needed based on age alone.

Dosing and How Age-Related Physiology Changes the Picture

The standard dose is 45 mg orally once daily, taken at the same time each day, with or without food. No dose reduction is required based on age alone, per the FDA-approved prescribing information. However, two pharmacokinetic realities affect women over 60 more than younger postmenopausal women.

Renal Function Declines With Age

Fezolinetant and its active metabolite (ES259564) are partially renally cleared. The FDA label states that dose adjustment is not required for mild or moderate renal impairment, but fezolinetant is not recommended in severe renal impairment or end-stage renal disease. Glomerular filtration rate (GFR) declines at roughly 1 mL/min/year after age 40 in women. By age 65, many women have a GFR between 45 and 75 mL/min, technically mild-to-moderate impairment, which is permissible. Still, knowing your current eGFR before starting is sound clinical practice.

Hepatic Metabolism and CYP1A2

Fezolinetant is metabolized primarily by CYP1A2. This is the most clinically consequential pharmacokinetic detail for older women. Many medications common in your 60s, including certain antidepressants, antipsychotics, and the antibiotic ciprofloxacin, are either CYP1A2 substrates or inhibitors. Co-administration with strong CYP1A2 inhibitors such as fluvoxamine is contraindicated, because fezolinetant plasma concentrations can rise approximately 8-fold, dramatically increasing liver toxicity risk. Moderate CYP1A2 inhibitors such as ciprofloxacin and mexiletine should also be avoided.

Bring your complete medication list to your prescriber. This is not optional.

Liver Safety: The Monitoring Protocol You Must Follow

Liver enzyme elevations are the most significant safety signal for fezolinetant. In the SKYLIGHT clinical program, liver enzyme elevations (ALT or AST above three times the upper limit of normal) occurred in approximately 2-3% of women on fezolinetant vs <1% on placebo. The elevations were generally asymptomatic and resolved after discontinuation, but one case of drug-induced liver injury with jaundice was reported in early post-marketing surveillance.

The mandatory monitoring schedule is:

• Baseline liver function tests (ALT, AST, bilirubin) before starting
• Repeat at 4 weeks
• Repeat at 8 weeks
• Repeat at 12 weeks
• Then as clinically indicated

Fezolinetant is contraindicated in women with cirrhosis or moderate-to-severe hepatic impairment (Child-Pugh B or C). Women in their 60s who have metabolic-associated steatotic liver disease (MASLD), formerly called NAFLD, should discuss baseline liver status with their clinician before starting. Alcohol use, which may affect hepatic enzyme levels, should also be disclosed honestly.

What Symptoms to Watch

Stop fezolinetant and contact your provider immediately if you develop:

• Jaundice (yellowing of skin or eyes)
• Dark urine
• Severe fatigue or right-upper-quadrant pain
• Nausea with no other explanation

These may indicate drug-induced liver injury and require urgent evaluation.

Comparing Veozah to Other Options for Women 60 and Older

At 60 and beyond, your menu of options for VMS differs from that of a woman in early perimenopause. The following framework can guide a shared decision conversation with your clinician.

Hormone Therapy

The 2023 Menopause Society Position Statement states that hormone therapy remains the most effective treatment for VMS and is appropriate for healthy women under age 60 or within 10 years of menopause onset, but that the benefit-risk ratio shifts after age 60 or more than 10 years post-menopause. For a woman who is now 68 and last menstruated at 52, initiating systemic estrogen carries higher absolute cardiovascular risk because of the timing hypothesis ("window of opportunity"). Fezolinetant sidesteps that concern entirely.

Women with a personal history of estrogen receptor-positive breast cancer, prior venous thromboembolism, or unexplained vaginal bleeding should generally not use systemic estrogen. For these women, fezolinetant may be the most suitable prescription option currently available.

SSRIs and SNRIs

Paroxetine 7.5 mg (Brisdelle) is the only FDA-approved non-hormonal option for VMS other than fezolinetant. It reduces hot flash frequency by roughly 33-65% in clinical trials, generally less than fezolinetant's reductions in head-to-head context. Low-dose venlafaxine and escitalopram are also used off-label. These options may be preferable if you are already on an SSRI for depression, but they carry sexual side effects and may not be desirable for women who are sensitive to serotonergic agents.

Gabapentin

Gabapentin reduces VMS but causes sedation and cognitive blunting, a concern for older women who are already at higher baseline risk for falls and cognitive changes.

Oxybutynin

Off-label use at low doses (2.5-5 mg) shows modest VMS benefit in small trials, but anticholinergic load is a genuine concern in women over 60 given associations with cognitive impairment.

Fezolinetant's targeted mechanism and lack of hormonal or anticholinergic activity gives it a distinct profile for women in this age group.

Pregnancy, Lactation, and Contraception: Why This Section Still Applies

By your 60s, pregnancy is biologically not possible through natural conception. You are postmenopausal. This section is therefore brief, but it matters for completeness and for any reader who arrives at this article from a search query without yet knowing whether they are truly postmenopausal.

Fezolinetant is not approved for use during pregnancy and should not be taken by pregnant women. Animal reproduction studies showed adverse developmental effects at doses exceeding clinical exposure. Human data are absent. Fezolinetant is also not studied in lactation; NK3 receptor antagonism has theoretical effects on prolactin signaling, though the clinical relevance in a postmenopausal woman is zero.

For any woman who is not yet confirmed postmenopausal (FSH persistently above 30 IU/L on two measurements at least 12 months apart after her final period), clinicians should confirm menopausal status before prescribing. A woman in her early 60s who stopped menstruating at 59 has had more than 12 months without a period and is postmenopausal by standard definition. Spontaneous pregnancy at 60 or beyond is biologically negligible in the absence of donor embryo technology.

Contraception is not required for women who are confirmed postmenopausal.

Conditions and Comorbidities Common at This Life Stage

Women in their 60s carry a different burden of comorbidities than younger postmenopausal women. Several are worth addressing directly.

Cardiovascular Disease

Fezolinetant does not affect lipids, blood pressure, or coagulation based on data from the SKYLIGHT program. The FDA prescribing information contains no cardiovascular contraindications. This is an advantage over systemic estrogen, which raises VTE risk and, in older women, may increase coronary events when initiated late.

Osteoporosis and Bone Health

Estrogen has direct protective effects on bone. Fezolinetant does not replace estrogen and therefore does not protect bone. Women in their 60s are at substantially elevated fracture risk: the National Osteoporosis Foundation notes that one in two women over 50 will experience an osteoporosis-related fracture in their lifetime. If you choose fezolinetant over hormone therapy partly because of estrogen risk concerns, discuss bone-specific screening (DEXA scan) and treatment options (bisphosphonates, denosumab, or romosozumab if indicated) with your provider. Fezolinetant addresses hot flashes. It does nothing for bone.

Genitourinary Syndrome of Menopause (GSM)

Vaginal dryness, dyspareunia, and urinary urgency are highly prevalent in women in their 60s. GSM affects up to 45% of postmenopausal women and worsens over time without treatment. Fezolinetant does not treat GSM. Local vaginal estrogen (estradiol cream, ring, or tablet; ospemifene; or intravaginal DHEA/prasterone) can be combined with fezolinetant because local estrogen has negligible systemic absorption. If GSM is your only or dominant symptom, fezolinetant is not the right tool.

Breast Cancer Survivors

Women who have completed treatment for estrogen receptor-positive breast cancer frequently experience severe hot flashes, partly from aromatase inhibitor therapy. Fezolinetant has no estrogenic activity and does not stimulate estrogen receptors. The Menopause Society 2023 statement identifies neurokinin receptor antagonists as a preferred non-hormonal option for breast cancer survivors with VMS. Clinical trial data specifically in this population are limited; the SKYLIGHT trials excluded women on active cancer therapy. Data in breast cancer survivors on aromatase inhibitors or tamoxifen are being evaluated in ongoing studies. The extrapolation from the general postmenopausal population is reasonable but should be disclosed to you as extrapolation.

Cognitive Health

Women in their 60s are at the age where concerns about cognitive decline begin to surface. Fezolinetant does not appear to affect cognition negatively in trial data. Sleep improvement from reduced nocturnal hot flashes may confer indirect cognitive benefit, given the well-established association between sleep disruption and dementia risk. This is speculative and was not a primary endpoint in SKYLIGHT trials, but it is worth knowing.

Who This Is Right For and Who Should Look Elsewhere

Women in Their 60s Who Are Good Candidates

• You have confirmed moderate-to-severe VMS (seven or more per day, or significantly affecting sleep and quality of life)
• Hormone therapy is contraindicated (prior breast cancer, VTE, cardiovascular disease, strong personal preference against hormones)
• Your liver function is normal at baseline
• You are not taking strong CYP1A2 inhibitors
• Your eGFR is above 30 mL/min
• You are willing to complete the four-point liver monitoring schedule

Women Who Should Consider Alternatives First

• You have cirrhosis or significant liver disease
• You take fluvoxamine or another strong CYP1A2 inhibitor that cannot be substituted
• Your VMS are mild and you prefer watchful waiting or lifestyle changes
• GSM is your primary complaint, not hot flashes (local estrogen or prasterone will serve you better)
• You have severe renal impairment (eGFR <30 mL/min)
• Bone protection is a priority alongside VMS control (systemic hormone therapy addresses both)

Starting Fezolinetant: A Practical Checklist for Women 60+

Before your first dose, your clinician should have:

1. Measured baseline ALT, AST, and total bilirubin
2. Reviewed your complete medication list for CYP1A2 interactions
3. Confirmed your eGFR
4. Documented your menopausal status and reason for choosing non-hormonal treatment
5. Discussed the liver monitoring schedule and what symptoms require stopping the drug

The 2023 Menopause Society Position Statement recommends shared decision-making, meaning your priorities, not just clinical criteria, shape the choice. If hot flashes are waking you three to five times per night, disrupting your work, and making intimacy uncomfortable, that is a legitimate reason to treat aggressively with the best available tool for your situation.

How long should you continue? There is no established maximum duration. The SKYLIGHT 2 trial ran 52 weeks and showed sustained efficacy without significant new safety signals at one year. Long-term data beyond one year are not yet available. Your provider should reassess annually whether VMS continues to warrant treatment.

A Note on the Evidence Gap for Women Over 65

The SKYLIGHT trials enrolled women up to age 65. Data on women aged 66 to 75 are extrapolated from the 60-65 cohort and from the pharmacokinetic data showing no dose adjustment needed for age alone. Women have historically been under-represented in clinical trials, and older postmenopausal women even more so. If you are 68 or 72 and asking your doctor about Veozah, the honest answer is that you meet the approved indication (postmenopausal VMS), the mechanism does not change with age, but the clinical trial participants who most resemble you were in the 60-65 age band. There is no evidence of harm in older women, but also limited direct data. This is extrapolation, and you deserve to know that.

The ongoing post-marketing pharmacovigilance and real-world registry data will eventually fill this gap. Until then, the monitoring requirements, especially liver function, are your safety net.

Ask your provider: "Can you check my liver enzymes at week four, eight, and twelve? And what should I do if I feel unusually tired or notice my eyes look yellow?" Those two questions confirm that you understand the most important safety point.