Recommended SSRI for Vasomotor Symptoms
Low-dose paroxetine (7.5 mg daily) is the recommended SSRI for managing vasomotor symptoms, as it is the only FDA-approved non-hormonal medication specifically for this indication. 1, 2
First-Line Treatment Options
The management of vasomotor symptoms (hot flashes and night sweats) should follow this algorithm:
Non-hormonal pharmacologic options (preferred first-line when hormonal therapy is inappropriate)
- Paroxetine mesylate 7.5 mg daily (taken at bedtime)
- Other SSRIs/SNRIs at low doses (if paroxetine is contraindicated)
- Gabapentin or pregabalin (especially if sleep disturbance is prominent)
- Clonidine (less preferred due to side effect profile)
Hormonal therapy (consider after risk-benefit assessment)
Evidence for Paroxetine
Paroxetine has demonstrated significant efficacy in reducing vasomotor symptoms:
- Reduces hot flash frequency by 33-67% compared to 13.7-37.8% with placebo 1
- Decreases hot flash frequency by approximately 8.86 episodes per week at 4 weeks and 7.36 episodes per week at 12 weeks 3
- Benefits persist through 24 weeks of treatment 1
- Low-dose formulation (7.5 mg) minimizes side effects while maintaining efficacy 4
Important Considerations
Tamoxifen Interaction
- Caution: Paroxetine inhibits CYP2D6, which converts tamoxifen to its active metabolites 5
- For patients on tamoxifen, consider alternative SSRIs with less CYP2D6 inhibition 5
Dosing
- Lower doses are needed for vasomotor symptoms than for depression/anxiety 2
- Recommended dose: 7.5 mg once daily at bedtime 2
- Gradual tapering is recommended when discontinuing to prevent withdrawal symptoms 5
Side Effects
- Most adverse effects are mild-to-moderate 1
- Common side effects: nausea, fatigue, dizziness, dry mouth, reduced appetite 5, 2
- Side effects are typically dose-dependent, with better tolerability at lower doses (7.5-12.5 mg) 1, 2
Relapse Risk
- Approximately one-third of women experience relapse of symptoms after discontinuation 6
- Higher risk of relapse in women with pretreatment insomnia and those with weaker initial response 6
Alternative SSRIs/SNRIs
If paroxetine is contraindicated or not tolerated, consider:
- Venlafaxine (SNRI): Effective alternative with rapid onset of action, but may be less well tolerated than other options 5
- Citalopram: May be effective in patients who don't respond to venlafaxine 5
- Fluoxetine: Shows moderate efficacy but with variable response 5
- Sertraline: Mixed results in clinical trials, but may benefit some women 5
Other Non-SSRI Options
- Gabapentin: Particularly useful when given at bedtime for patients with sleep disturbances; one trial showed 46% reduction in hot flash severity score at 8 weeks 5
- Clonidine: Less preferred due to side effects including sleep difficulties, dry mouth, fatigue, and dizziness 5
Clinical Pearls
- Begin with low doses and titrate as needed
- Inform patients that response is typically faster than when these medications are used for depression
- Educate patients about the possibility of symptom relapse after discontinuation
- Consider the patient's concurrent medications, particularly tamoxifen, when selecting an SSRI