Hormonal Therapy for Hot Flashes in Perimenopausal Women
Hormonal therapy is advisable for perimenopausal women with moderate to severe hot flashes that impact quality of life, using the lowest effective dose for the shortest duration possible (typically not more than 4-5 years). 1, 2
Benefits of Hormonal Therapy
- Most effective treatment for vasomotor symptoms (hot flashes), reducing them by 70-80% compared to 20-40% with placebo 3
- Prevents genitourinary atrophy and associated symptoms 1
- Prevents bone loss and reduces fracture risk 1
- May reduce risk of colorectal cancer 1
Risks of Hormonal Therapy
- Increased risk of stroke, dementia, gallbladder disease, and urinary incontinence 4
- Combined estrogen/progestogen therapy increases breast cancer risk when used for more than 3-5 years 2
- May increase risk of venous thromboembolism 5
- Not recommended for women with active liver disease, history of breast cancer, coronary heart disease, previous venous thromboembolism or stroke 1
Recommended Approach
Step 1: Assess Severity and Impact
- Determine if hot flashes are moderate to severe and significantly impact quality of life
- Rule out contraindications: breast cancer, cardiovascular disease, liver disease, history of VTE or stroke 1, 5
Step 2: For Eligible Candidates, Consider Hormonal Options
First-line option: Transdermal estradiol 0.025-0.0375 mg/day patch (applied twice weekly) 1
- Lower thrombotic risk than oral formulations
- For women with intact uterus, add micronized progesterone 200 mg daily for 12-14 days per month to prevent endometrial cancer 1
Alternative: Oral conjugated equine estrogen 0.625 mg/day with medroxyprogesterone acetate 2.5 mg/day (if uterus intact) 1
Step 3: For Women with Contraindications or Who Prefer Non-Hormonal Options
Non-pharmacological approaches:
- Weight loss if overweight
- Smoking cessation
- Limiting alcohol intake
- Regular physical activity
- Cognitive behavioral therapy 4, 1
Pharmacological alternatives:
- SSRIs/SNRIs (venlafaxine, paroxetine, desvenlafaxine) 4, 6
- Caution with paroxetine in women taking tamoxifen due to drug interactions 4
- Gabapentin or pregabalin 4, 6
- Clonidine 4
Monitoring and Follow-up
Initial follow-up at 3 months
Annual follow-up thereafter to monitor:
- Blood pressure
- Weight
- Symptom control
- Bleeding patterns
- Annual mammography 1
Consider gradual dose reduction (25-50% every 4-8 weeks) when discontinuing therapy 1
Important Considerations
- Hormonal therapy should be used primarily for symptom management, not for prevention of chronic conditions 4
- Use the lowest effective dose for the shortest duration needed (typically not more than 4-5 years) 2, 7
- Non-hormonal options are approximately half as effective as estrogen but may be appropriate for women with contraindications 3
- Acupuncture may be equivalent to or better than some pharmacological treatments for vasomotor symptoms 4
Remember that while hormonal therapy remains the most effective treatment for hot flashes, the decision to use it should balance symptom severity against potential risks, with regular reassessment of the need for continued treatment.