What are the treatment options for hot flushes, particularly in the context of menopause?

Management of Hot Flushes in Menopause

For the management of hot flushes, nonhormonal pharmacologic options including SNRIs, SSRIs, gabapentin, and clonidine should be used as first-line therapy, with hormonal therapies considered only after careful risk-benefit assessment. 1

First-Line Nonhormonal Pharmacologic Options

SNRIs/SSRIs

• Venlafaxine (SNRI): Start with 37.5 mg daily, increasing to 75 mg daily after 1 week if symptoms persist 1

  • Rapid onset of action (within 1 week)
  • Reduces hot flash frequency and severity by 60-65%
  • Well-studied in breast cancer survivors

• Paroxetine (SSRI): Start with 10 mg daily, increasing to 20 mg daily after 1 week if needed 1

  • Low doses are effective for vasomotor symptoms (lower than doses used for depression)
  • CAUTION: Avoid in women taking tamoxifen due to CYP2D6 inhibition that may reduce tamoxifen effectiveness 1

• Common side effects: Dry mouth, decreased appetite, fatigue, nausea, constipation, and possible sexual dysfunction 1

  • Side effects are typically mild and short-lived
  • Gradually taper when discontinuing to minimize withdrawal symptoms

Anticonvulsants

• Gabapentin: 300 mg daily, gradually increasing to 900 mg daily (in divided doses) 1
  • Particularly effective for women with sleep disturbance from night sweats
  • Can be used as first-line or for women who don't respond to or cannot take SSRI/SNRIs
  • Side effects: Dizziness, drowsiness, unsteadiness

Antihypertensives

• Clonidine: 0.1 mg daily (oral or transdermal) 1
  • Moderate efficacy (reduces hot flashes by up to 46%)
  • Side effects: Dry mouth, insomnia or drowsiness
  • Useful for mild to moderate hot flashes

Nonpharmacologic Approaches

Lifestyle Modifications

• Environmental modifications: Cool rooms, dressing in layers, avoiding triggers 1
• Dietary changes: Limit spicy foods, caffeine, and alcohol 1
• Weight loss: For overweight women, losing ≥10% of body weight may reduce hot flashes 1
• Smoking cessation: May improve frequency and severity of hot flashes 1

Complementary Therapies

• Acupuncture: Some studies show equivalent or better results than venlafaxine or gabapentin 1
• Cognitive behavioral therapy (CBT): May help manage hot flashes 1
• Yoga: May improve quality of life associated with menopause 1

Special Considerations for Cancer Survivors

• In breast cancer survivors, avoid hormonal therapies, especially with estrogen receptor-positive cancers 1
• For women on tamoxifen, avoid paroxetine and fluoxetine; consider venlafaxine, citalopram, or gabapentin 1
• For men on androgen deprivation therapy (ADT) experiencing hot flashes, consider venlafaxine or gabapentin 1

Hormonal Options (Second-Line)

• Menopausal hormone therapy (MHT): Most effective but should be used cautiously after risk assessment 1
  • Contraindicated in women with history of hormonally mediated cancers, abnormal vaginal bleeding, recent thromboembolic events, and active liver disease
  • Transdermal estrogen formulations preferred due to lower VTE and stroke risk
  • Use lowest effective dose for shortest duration needed

Algorithm for Treatment Selection

1. Assess severity and impact on quality of life
2. Rule out other causes (thyroid disease, diabetes)
3. Start with nonpharmacologic approaches for mild symptoms
4. For moderate to severe symptoms:
   • If no contraindications: SNRI/SSRI (venlafaxine or paroxetine) OR gabapentin
   • If on tamoxifen: Avoid paroxetine, use venlafaxine, citalopram, or gabapentin
   • If no response after 4 weeks: Switch to alternative nonhormonal option
   • If still inadequate response: Consider hormonal therapy if no contraindications

Monitoring and Follow-up

• Evaluate response after 4 weeks; if no improvement, treatment is unlikely to be effective 1
• Monitor for side effects, especially during initial weeks of therapy
• For women who respond to treatment, continue therapy as needed and reassess periodically

Remember that hot flushes typically improve over time for most women, though they may persist for years in some cases.