From the Guidelines
Paroxetine (Paxil) at a dose of 7.5 mg daily is the most effective SSRI for treating hot flashes, as evidenced by a randomized clinical trial in healthy postmenopausal women showing a reduction in the frequency and severity of hot flashes 1.
Key Considerations
- The use of paroxetine should be approached with caution in women taking tamoxifen for breast cancer, as it can interfere with tamoxifen metabolism by inhibiting cytochrome P450 2D6 (CYP2D6) 1.
- Alternative SSRIs such as escitalopram (10-20 mg daily) and citalopram (10-20 mg daily) may be considered, especially in cases where paroxetine is not suitable due to potential interactions with tamoxifen 1.
- Common side effects of SSRIs include nausea, headache, insomnia, and sexual dysfunction, and these medications should be started at a low dose and taken at the same time each day to minimize side effects.
Treatment Approach
- Improvement in hot flash symptoms typically occurs within 2-4 weeks of starting treatment with an SSRI.
- Treatment should continue as long as symptoms persist, with regular monitoring for efficacy and side effects.
- In cases where SSRIs are not effective or suitable, alternative nonhormonal pharmacologic options such as anticonvulsants (e.g., gabapentin, pregabalin) may be considered 1.
From the Research
Effective SSRIs for Hot Flashes
The following SSRIs have been found to be effective in reducing the frequency and severity of hot flashes:
- Paroxetine (Paxil) 2, 3, 4
- Citalopram (Celexa) 2, 4
- Escitalopram (Lexapro) 2, 4
- Sertraline 5, 4
- Fluoxetine 5, 4
Comparison of SSRIs
While several studies suggest that these SSRIs are effective, no studies have compared them directly to determine a single best option 5. However, paroxetine and venlafaxine have been studied more extensively and are more consistent in effectively reducing the frequency and severity of hot flashes 4.
Considerations for Treatment
Treatment choice should be patient-specific and begin with the lowest dose available 2. Women with a history of breast cancer and taking tamoxifen should avoid SSRIs, which have been shown to interfere with tamoxifen metabolism 2. SNRIs, such as venlafaxine, may be a safer option for this population 2, 4.
Additional Therapies
Augmentation of SSRI/SNRI therapy with hypnotic agents, such as zolpidem, may improve sleep and quality of life in breast cancer survivors with hot flashes and associated sleep disturbance 6.