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Menopause Matters

Treating Hot Flashes Options to Estrogen

Andrew M. Kaunitz, MD

Hot flashes represent the most common manifestation of menopause. They usually follow a consistent pattern that is unique for each woman. Although some hot flashes are easily tolerated, others can be debilitating.

In almost all women, menopause-related hot flashes will abate over time without any intervention; however, when therapy is needed, various pharmacologic and nonpharmacologic treatments are available. Treatment selection depends primarily on the severity of the hot flashes. Prescription estrogen therapy (with or without progestogen) remains the most effective medical treatment for hot flashes, and it is the only therapy approved by the US Food and Drug Administration for treating this condition. However, some women cannot or choose not to use estrogen.

LIFE-STYLE CHANGES

For control of mild hot flashes, life-style changes should be considered. Although the efficacy of each of these treatments has not been shown in randomized, controlled clinical trials, anecdotal data suggest they provide relief in some symptomatic women. Life-style recommendations that may reduce mild hot flashes include the following:

• Identify and minimize exposure to personal hot flash triggers, which may include external heat (eg, warm rooms, using a hair dryer), strong emotions, hot drinks, hot or spicy foods, alcohol, caffeine, and cigarette smoking.
  
  
• Keep cool by dressing in layers, using a fan, and sleeping in a cool room.
  
  
• Exercise regularly to reduce stress and promote better, more restorative sleep; however, be aware that strenuous exercise can trigger hot flashes in unconditioned women.
  
  
• Reduce stress through meditation, yoga, biofeedback, positive visualization, massage, or by taking a leisurely bath.
  
  
• When a hot flash is starting, try paced respiration (ie, slow, deep, abdominal breathing).
  

NONPRESCRIPTION APPROACHES

Some women find relief from mild hot flashes by using foods or supplements purchased without a prescription. It is important for health care professionals to caution women that health claims made by marketers of some of these supplements may be unsubstantiated, as government regulations regarding these products are not as strict or as well enforced as they are with prescription drugs. Some nonprescription options for possible relief of mild hot flashes include isoflavones, black cohosh, vitamin E, and progesterone cream.

Isoflavones

Randomized, controlled clinical studies with isoflavones, derived from either soy or red clover, have shown that, in general, isoflavones only slightly reduce hot flashes when compared with placebo.¹ Eating 1 or 2 servings of soy foods daily may be preferable to taking supplements.

Black Cohosh

In some randomized, controlled trials of black cohosh, women reported improvement in mild hot flashes from taking two 20-mg tablets (Remifemin), although not all studies show this positive effect.2 Side effects are rare. Safety beyond 6 months use is not known.

Vitamin E

The first well-controlled trial of vitamin E found it was no more effective than placebo in relieving menopausal symptoms.³ In women with breast cancer, a randomized, placebo-controlled trial found vitamin E relieved hot flashes, although the between-group differences were small.⁴ Vitamin E, at doses of up to 800 IU/day, is virtually nontoxic. A generalized increase in bleeding risk has not been documented,⁵ even in individuals on chronic warfarin and taking vitamin E doses as high as 1,200 IU/day for 1 month.⁶

Progesterone Cream

Two randomized, placebo-controlled trials have assessed the efficacy of progesterone cream in treating hot flashes.^7,8 One of these studies⁷ reported better efficacy with progesterone cream (20 mg/day) than placebo. The other trial⁸ failed to note any benefit using a larger dose (32 mg/day). More research is needed before progesterone cream can be recommended for the treatment of hot flashes.

PRESCRIPTION THERAPIES

Many women suffer persistent hot flashes that require prescription medications. Although estrogen is considered the prescription treatment standard for hot flashes, there are nonestrogen therapies that may be effective for some women, even those with more severe hot flashes. However, these are not necessarily appropriate for all women.

Progestogens

Several progestogens have been shown to effectively treat hot flashes. In double-blind, placebo-controlled trials, medroxyprogesterone acetate has relieved menopause-associated hot flashes in otherwise healthy women, as well as in women with breast or endometrial cancer.⁹ Both intramuscular and oral forms of progestogen have demonstrated efficacy. Another oral progestin, megestrol acetate (Megace), also offers an effective option for treating hot flashes.

Antidepressants

Antidepressants, such as fluoxetine (Prozac), paroxetine (Paxil), and venlafaxine (Effexor), appear effective in relieving hot flashes. Most of the trials were conducted in women with a history of breast cancer. Venlafaxine has been shown to provide relief of hot flashes at 25 to 250 mg/day.¹⁰ Both fluoxetine (20 mg/day for 4 weeks) and paroxetine (10 mg/day for 1 week followed by 20 mg/day for 4 weeks) have shown efficacy in a small number of clinical trials.^11-13 Paroxetine (12.5 or 25 mg/day controlled-release formulation) also was recently shown to be effective in a general population of postmenopausal women, few of whom were breast cancer survivors.¹⁴

Gabapentin

The anticonvulsant gabapentin (Neurontin), 900 mg/day for 12 weeks, was shown to effectively reduce hot flashes in the only randomized, controlled clinical trial to date.¹⁵

FINDING RELIEF

For perimenopausal and postmenopausal women experiencing disabling hot flashes, estrogen continues to represent the most effective treatment. Nonetheless, life-style measures, nonprescription approaches, and nonestrogen prescription therapies may offer help for some women with this common manifestation of menopause. For more information about meno-pause, see the NAMS Web site (www.menopause.org).

Andrew M. Kaunitz, MD is professor and assistant chair, Department of Obstetrics and Gynecology, University of Florida Health Science Center in Jacksonville; and Chair of the 2003-2004 Professional Education Committee of The North American Menopause Society.

REFERENCES

1. The North American Menopause Society. The role of isoflavones in menopausal health: consensus opinion of The North American Menopause Society. Menopause. 2000;7(4):215-229.
2. Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled trials. Ann Intern Med. 2002;137(10):805-813.
3. Blatt MHG, Wiesbader H, Kupperman HS. Vitamin E and climacteric syndrome; failure of effctive control as measured by menopausal index. Arch Intern Med. 1953;91(6):792-796.
4. Barton DL, Loprinzi CL, Quella SK, et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. J Clin Oncol. 1998;16(2):495-500.
5. Meydani SN, Meydani M, Blumberg JB, et al. Assessment of the safety of supplementation with different amounts of vitamin E in healthy older adults. Am J Clin Nutr. 1998;68(2): 311-318.
6. Kim JM, White RH. Effect of vitamin E on the anticoagulant response to warfarin. Am J Cardiol. 1996;77(7): 545-546.
7. Leonetti HB, Longo S, Anasti JN. Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss. Obstet Gynecol. 1999;94(2):225-228.
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9. The North American Menopause Society. Role of progestogen in hormone therapy for postmenopausal women: position statement of The North American Menopause Society. Menopause. 2003;10(2):113-132.
10. Loprinzi CL, Kugler JW, Sloan JA, et al. Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial. Lancet 2000;356(9247):2059-2063.
11. Loprinzi CL, Sloan JA, Perez EA, et al. Phase III evaluation of fluoxetine for treatment of hot flashes. J Clin Oncol. 2002;20(6):1578-1583.
12. Stearns V, Isaacs C, Rowland J, et al. A pilot trial assessing the efficacy of paroxetine hydrochloride (Paxil) in controlling hot flashes in breast cancer survivors. Ann Oncol. 2000;11(1):17-22.
13. Weitzner MA, Moncello J, Jacobsen PB, Minton S. A pilot trial of paroxetine for the treatment of hot flashes and associated symptoms in women with breast cancer. J Pain Symptom Manage. 2002;23(4):337-345.
14. Stearns V, Beebe KL, Iyengar M, Dube E. Paroxetine controlled release in the treatment of menopausal hot flashes: a randomized, controlled trial. JAMA. 2003;289(21):2827-2834.
15. Guttuso T Jr, Kurlan R, McDermott MP, Kieburtz K. Gabapentin’s effects on hot flashes in postmenopausal women: a randomized controlled trial. Obstet Gynecol. 2003;101(2):337-345.

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