What are the management options for hot flushes?

Management Options for Hot Flushes

For hot flushes management, first-line pharmacological options include SNRIs (particularly venlafaxine), SSRIs, gabapentin, and lifestyle modifications, with treatment selection based on symptom severity, comorbidities, and patient preference. 1, 2

Pharmacological Management

First-Line Options

1. SNRIs/SSRIs

   • Venlafaxine: 75 mg/day (first-line), reduces hot flash scores by 61% compared to placebo 2
   • Paroxetine: 7.5 mg daily (caution with tamoxifen due to CYP2D6 inhibition) 1, 2
   • Citalopram/Fluoxetine/Sertraline: Alternative options with variable efficacy 2
   • Side effects: Nausea, dry mouth, decreased appetite, constipation, sexual dysfunction 1
   • Important note: Taper gradually when discontinuing to prevent withdrawal symptoms 1

2. Anticonvulsants

   • Gabapentin: Start at 300mg at bedtime, gradually increase to 900mg/day (reduces hot flashes by 51% vs 26% with placebo) 1, 2
   • Particularly useful: For patients with sleep disturbances due to somnolence side effect 1
   • Advantages: No known drug interactions, no sexual dysfunction, no withdrawal syndrome 2

3. Antihypertensives

   • Clonidine: 0.1mg/day (reduces hot flashes by up to 46%) 1, 2
   • Less preferred due to side effects: Sleep difficulties, dry mouth, fatigue, dizziness, nausea 1

Comparative Efficacy

• Venlafaxine works faster but is less well tolerated than clonidine 1
• In crossover studies, 68% of patients preferred venlafaxine over gabapentin despite similar efficacy in reducing hot flash severity 1

Non-Pharmacological Management

1. Lifestyle Modifications

   • Dressing in layers
   • Using cold packs
   • Identifying and avoiding personal triggers (e.g., alcohol, caffeine, spicy foods) 1, 2, 3
   • Weight management (goal of ≥10% weight loss if overweight) 2
   • Regular moderate exercise (150 minutes weekly) 1, 2
   • Smoking cessation 2

2. Complementary Approaches

   • Acupuncture: Shown to be equivalent to or better than venlafaxine or gabapentin in some studies 1
   • Paced respiration/relaxation techniques: Significant benefit with moderate evidence 2
   • Cognitive behavioral therapy (CBT): Helpful for managing psychological aspects of hot flushes 1, 2

3. Other Options

   • Yoga: May improve quality of life associated with menopause 1
   • Phytoestrogens/botanicals/supplements: Mixed or limited evidence (category 2B recommendation) 1
   • Vitamin E: Marginal improvement but mixed results 1
   • Black cohosh: Possible benefit in general population but no benefit shown in breast cancer survivors 1

Special Considerations

For Cancer Survivors

• Avoid paroxetine in patients on tamoxifen due to CYP2D6 inhibition 1, 2
• Preferred options: Venlafaxine, gabapentin, clonidine 1
• Avoid systemic hormone therapy in breast cancer survivors 1
• For vaginal symptoms, use non-hormonal moisturizers and lubricants 2

For Patients with Aromatase Inhibitors

• Higher incidence of vaginal dryness compared to tamoxifen users 2
• Avoid estradiol preparations as they may increase circulating estradiol levels 2
• Consider estriol-containing preparations as they cannot convert to estradiol 2

For Patients with Sleep Disturbances

• Gabapentin may be particularly beneficial due to somnolence side effect 1, 2

Treatment Algorithm

1. Initial Assessment:

   • Determine severity of symptoms
   • Screen for contraindications to medication options
   • Evaluate cardiovascular risk factors 2

2. First-Line Treatment:

   • For mild symptoms: Start with lifestyle modifications
   • For moderate to severe symptoms: Add pharmacological therapy based on comorbidities:
     • If sleep disturbance predominant: Gabapentin
     • If mood symptoms present: SNRI/SSRI (venlafaxine preferred)
     • If hypertensive: Consider clonidine

3. Follow-up at 4 weeks:

   • If inadequate improvement: Adjust dose, switch agent, or add complementary approaches 2
   • Monitor for side effects (10-20% discontinue venlafaxine due to side effects) 2

4. Long-term Management:

   • Periodically reassess need for continued therapy
   • For SNRIs/SSRIs: Ensure gradual tapering when discontinuing 1

Pitfalls and Caveats

• Hormone replacement therapy carries significant risks (stroke, DVT, PE, MI, breast cancer) and should be avoided or used with extreme caution 2
• Immersion in ice or cold water should be limited (e.g., 10 minutes, 4 times daily) to prevent tissue damage 1
• Powerful fans near extremities can lead to equivalent of windburn 1
• SSRIs that inhibit CYP2D6 (e.g., paroxetine) may reduce conversion of tamoxifen to active metabolites 1

By following this structured approach to hot flush management, clinicians can effectively address this common and distressing symptom while minimizing risks and side effects.