What medications are used to manage hot flashes?

Medications for Hot Flashes Management

Nonhormonal medications should be used as first-line therapy for hot flashes, with options including gabapentin, SSRIs, and SNRIs, while hormonal therapy remains the most effective treatment but carries significant risks that must be carefully considered. 1

First-Line Treatment: Nonhormonal Options

Antidepressants (SSRIs/SNRIs)

• Venlafaxine (SNRI)

  • Starting dose: 37.5 mg daily
  • Can increase to 75 mg after 1 week if greater symptom control is needed
  • Effective for reducing both frequency and severity of hot flashes
  • Side effects: dry mouth, reduced appetite, nausea, constipation 1

• Paroxetine (SSRI)

  • Dosage: 10-20 mg daily (lower doses often sufficient)
  • Reduces hot flash frequency by 40-51% and severity by 45-56%
  • Side effects: nausea, dizziness, insomnia 1
  • Caution: Avoid in women taking tamoxifen as it inhibits CYP2D6, potentially reducing tamoxifen's effectiveness 1

Anticonvulsants

• Gabapentin
  • Dosage: 900 mg/day (300 mg three times daily)
  • Reduces hot flash severity by 46% at 8 weeks
  • Acts through central temperature regulatory centers
  • Side effects: somnolence, fatigue 1
  • Particularly useful for women with nighttime hot flashes or sleep disturbances

Second-Line Treatment: Hormonal Options

Menopausal Hormone Therapy (MHT)

• Most effective treatment for hot flashes (70-80% reduction vs. 20-40% with placebo) 2

• Estrogen options:

  • Transdermal formulations preferred due to lower risk of venous thromboembolism and stroke 1
  • For women with intact uterus: must combine with progestin to prevent endometrial cancer 3, 4
  • For women without uterus: estrogen alone is sufficient 1

• Progestin options:

  • Micronized progesterone preferred over medroxyprogesterone acetate due to lower VTE and breast cancer risk 1
  • Common side effects: breast tenderness, headaches, mood changes 4

Important Contraindications for Hormonal Therapy

• History of hormonally mediated cancers
• Abnormal vaginal bleeding
• Recent thromboembolic events
• Active liver disease
• Pregnancy 1

Other Options

Clonidine

• Available in oral and transdermal formulations
• Reduces hot flashes in a dose-dependent manner
• Side effects: dry mouth, constipation, drowsiness 1

Complementary Approaches (Limited Evidence)

• Vitamin E: modest improvement compared to placebo
• Black cohosh: no significant difference from placebo in controlled trials
• Relaxation techniques, acupuncture, avoidance of caffeine and alcohol: potentially beneficial but limited evidence 1

Special Considerations

For Cancer Survivors

• Nonhormonal options strongly preferred
• For breast cancer patients on tamoxifen: avoid paroxetine and fluoxetine; consider venlafaxine or citalopram which have minimal effects on tamoxifen metabolism 1

For Men on Androgen Deprivation Therapy (ADT)

• Consider alternative ADT options (intermittent ADT or antiandrogen monotherapy) if hot flashes are disruptive to quality of life 1

Clinical Pearls and Pitfalls

1. Placebo effect is substantial - 25% or more reduction in hot flashes with placebo alone, which may explain why many complementary therapies appear effective in uncontrolled studies 1

2. Medication interactions - Be vigilant about drug interactions, particularly with SSRIs and tamoxifen in breast cancer survivors 1

3. Lowest effective dose - Always use the lowest effective dose of any medication to control symptoms, particularly with hormonal therapies 3

4. Time-limited therapy - Hot flashes often decrease over time; periodic reassessment of the need for continued therapy is recommended 1

5. Combination therapy - Some patients may benefit from combining approaches (e.g., gabapentin for nighttime, SNRI for daytime symptoms) when single-agent therapy is insufficient