From the Guidelines
Hormone replacement therapy (HRT) using estrogen, often combined with progesterone, is the most effective treatment for hot flashes during menopause, but should be used with caution due to potential health risks, as evidenced by the 2017 NCCN clinical practice guidelines 1.
Treatment Options
The treatment options for hot flashes using estrogen and progesterone include:
- Combination estrogen and progesterone for survivors with an intact uterus
- Estrogen alone for those without a uterus
- Different local and systemic formulations of hormones, including oral, transdermal, vaginal ring, and an intrauterine device
Recommended Formulations
Estrogen transdermal formulations may be preferred over other formulations due to lower rates of venous thromboembolism (VTE) and stroke, as suggested by the 2017 NCCN guidelines 1. Additionally, micronized progestin may be preferred over medroxyprogesterone acetate (MPA) due to lower rates of VTE and breast cancer risk.
Important Considerations
When using HRT, it is essential to:
- Start at the lowest effective dose
- Use treatment for up to 5 years in most women without significant risk
- Consider alternatives to HRT, such as non-hormonal therapies, for women with a history of breast cancer, stroke, heart disease, or blood clots
- Refer patients to an appropriate specialist for dosing and management of HRT
Contraindications
HRT is contraindicated in survivors with a history of hormonally mediated cancers, as well as those with a history of abnormal vaginal bleeding, active or recent history of thromboembolic event, pregnancy, and active liver disease.
Alternative Options
Other hormonal options for treating hot flashes include novel therapies that combine a selective estrogen receptor modulator (SERM) with estrogen, creating a tissue selective estrogen complex, such as a conjugated estrogen and the SERM bazedoxifene, which is FDA-approved for treating menopausal symptoms in healthy postmenopausal women 1.
From the FDA Drug Label
When estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should also be initiated to reduce the risk of endometrial cancer. For treatment of moderate to severe vasomotor symptoms, vulval and vaginal atrophy associated with the menopause, the lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. Estradiol is used to: reduce moderate to severe hot flashes
The treatment options for hot flashes using estrogen (estradiol) and progesterone (progestin) are:
- Estradiol alone for women without a uterus
- Estradiol in combination with a progestin for women with a uterus to reduce the risk of endometrial cancer
- The lowest effective dose and regimen should be chosen to control symptoms, and medication should be discontinued as promptly as possible 2
- Estradiol is used to reduce moderate to severe hot flashes 2
From the Research
Treatment Options for Hot Flashes
The treatment options for hot flashes using estrogen and progesterone include:
- Combined estrogen/progestogen therapy, which is recommended for women with a uterus to treat menopausal symptoms such as hot flashes and vaginal atrophy, using the smallest effective dosage for the shortest possible duration 3
- Estrogen therapy, which is the most effective treatment for hot flashes, but may increase the risk of breast cancer when used for more than three to five years 3, 4, 5
- Progesterone therapy, which may have an independent effect on relieving hot flashes, and can be used as an alternative to estrogen therapy in selected menopausal patients 6, 7
- Combination therapy with estrogen and progesterone, which can be used to reduce the risk of endometrial cancer in women with a uterus 3
Non-Hormonal Alternatives
Non-hormonal alternatives for treating hot flashes include:
- Low-dose paroxetine, venlafaxine, and gabapentin, which are effective alternatives to hormone therapy 3, 4
- Selective serotonin-uptake-inhibitor anti-depressants and anti-convulsants, which have yielded promising results in small studies 6
- Soy products, black cohosh, and vitamin E, which may have a modest and delayed improvement of symptoms, but have inconsistent and variable effects 6
Considerations for Treatment
When considering treatment options for hot flashes, it is essential to:
- Evaluate the risks and benefits of hormone therapy, including the increased risk of breast cancer and endometrial cancer 3
- Consider the patient's medical history, including any contraindications or personal reservations to estrogen replacement therapy 4
- Discuss the treatment options with the patient and determine the best course of treatment based on their individual needs and preferences 3