What medications are used to treat hot flashes?

Medications for Hot Flashes

For most women experiencing hot flashes, non-hormonal medications such as venlafaxine, gabapentin, or paroxetine should be used as first-line pharmacological treatment due to their proven efficacy and favorable safety profiles. 1

First-Line Pharmacological Options

SNRIs/SSRIs

• Venlafaxine (SNRI):

  • Start at 37.5 mg daily
  • May increase to 75 mg after 1 week if greater symptom control is needed
  • Reduces hot flash frequency and severity by 40-60%
  • Side effects: dry mouth, reduced appetite, nausea, constipation 1

• Paroxetine (SSRI):

  • 10-12.5 mg daily is effective (higher doses don't show additional benefit)
  • Reduces hot flash frequency by 40-50% and severity by 45-65%
  • Side effects: nausea, dizziness, insomnia 1
  • Important caution: Avoid in women taking tamoxifen as it may reduce tamoxifen's effectiveness by inhibiting CYP2D6 enzyme 1

Anticonvulsants

• Gabapentin:
  • Start at 300 mg daily, can increase to 900 mg daily
  • 900 mg daily reduces hot flash severity by 46-49%
  • Side effects: somnolence, fatigue 1
  • Most effective at higher doses (900 mg/day) 1

Special Considerations for Breast Cancer Patients

For women with a history of breast cancer or those taking tamoxifen:

• Venlafaxine is preferred over SSRIs (minimal effect on tamoxifen metabolism) 1
• Gabapentin is a good alternative 1
• Avoid estrogen-containing products as they may increase cancer recurrence risk 1
• Avoid paroxetine and fluoxetine in women taking tamoxifen due to drug interactions 1

Second-Line Options

• Clonidine (oral or transdermal):

  • Reduces hot flashes in a dose-dependent manner
  • Side effects: dry mouth, constipation, drowsiness 1

• Megestrol acetate (progestational agent):

  • Can decrease hot flashes by approximately 80%
  • May be safe for women with breast or uterine cancer history 2

Non-Pharmacological Approaches

Before or alongside medication, consider:

• Weight loss if overweight
• Smoking cessation
• Limiting alcohol intake
• Regular physical activity
• Cognitive behavioral therapy 3
• Environmental modifications (cool rooms, dressing in layers) 1

Treatments to Avoid or Use with Caution

• Estrogen therapy: Most effective treatment (80-90% reduction) but contraindicated in women with history of breast cancer, venous thromboembolism, stroke, or active liver disease 4, 2
• Estrogen/progestin combinations: Not recommended for women taking tamoxifen or raloxifene 1
• Vitamin E: Limited efficacy (modest benefit at 800 IU/day) 2, 5
• Black cohosh, botanical products: No consistent evidence of benefit beyond placebo 6

Treatment Algorithm

1. Assess severity and impact on quality of life

   • For mild symptoms: Try non-pharmacological approaches first
   • For moderate to severe symptoms: Proceed to pharmacological options

2. Rule out contraindications:

   • History of breast/uterine cancer → Avoid hormonal options
   • Taking tamoxifen → Avoid paroxetine/fluoxetine

3. Select appropriate medication:

   • No contraindications to hormone therapy → Consider low-dose estrogen (most effective)
   • Contraindications to hormone therapy → Start with venlafaxine or gabapentin
   • On tamoxifen → Choose venlafaxine or gabapentin

4. Titrate dose based on response:

   • Start with lowest effective dose
   • Increase if needed after 1-4 weeks
   • Continue for shortest duration needed to control symptoms

5. Monitor for side effects and efficacy:

   • Reassess at 4-8 weeks
   • Consider switching medication if inadequate response or intolerable side effects

Remember that hot flashes often improve over time, and the goal is to use the lowest effective dose for the shortest duration needed to maintain quality of life.