What medications are used to treat hot flashes?

Medications for Hot Flashes

For managing hot flashes, non-hormonal medications including SSRIs/SNRIs (particularly venlafaxine), gabapentin, and paroxetine are the first-line treatments due to their proven efficacy and safety profiles, especially in patients with contraindications to hormone therapy. 1

First-Line Non-Hormonal Options

SSRIs/SNRIs

• Venlafaxine (SNRI)

  • Starting dose: 37.5 mg daily
  • Can increase to 75 mg after 1 week if greater symptom control is needed
  • Reduces hot flash frequency and severity by approximately 60% 2
  • Side effects: mouth dryness, reduced appetite, nausea, constipation
  • Minimal interaction with tamoxifen (important for breast cancer patients) 1

• Paroxetine (SSRI)

  • Dosage: 10-12.5 mg daily (low-dose formulation)
  • Reduces hot flash composite score by 40-62% 1
  • Side effects: nausea, dizziness, insomnia
  • Caution: Avoid in women taking tamoxifen due to CYP2D6 inhibition 1

Anticonvulsants

• Gabapentin
  • Dosage: 900 mg/day (300 mg three times daily)
  • Reduces hot flash severity by 46-49% 1
  • Particularly useful when given at bedtime for patients with sleep disturbances 1
  • Side effects: somnolence, fatigue (generally mild) 1

Other Options

• Clonidine
  • Available in oral and transdermal formulations
  • Dose-dependent reduction in hot flashes
  • Side effects: dry mouth, constipation, drowsiness 1
  • Less effective than other options with more side effects 2

Special Considerations

For Breast Cancer Patients on Tamoxifen

• Hot flashes affect approximately 80% of women on tamoxifen 1
• Preferred options:
  • Venlafaxine or citalopram (minimal effect on tamoxifen metabolism) 1
  • Gabapentin (no interaction with tamoxifen) 1
• Avoid: Paroxetine and fluoxetine due to CYP2D6 inhibition which may reduce tamoxifen efficacy 1

Hormone Therapy Considerations

• Estrogen therapy is the most effective treatment for hot flashes (80-90% reduction) 2, 3
• Contraindications: history of breast cancer, active liver disease, history of abnormal vaginal bleeding, previous venous thromboembolism, stroke, or coronary heart disease 4
• For women with a uterus, combined estrogen-progestogen therapy is required to prevent endometrial cancer 5
• Estrogen and/or progestins should not be used for treating hot flashes in women taking SERMs (tamoxifen, raloxifene) 1

Treatment Algorithm

1. Assess severity and impact on quality of life

   • For mild symptoms that don't interfere with sleep or daily function: behavioral modifications first

2. For moderate to severe symptoms:

   • If no contraindications to hormone therapy: Consider low-dose estrogen therapy
   • If contraindicated or unwilling to use hormone therapy:
     • First choice: Venlafaxine 37.5 mg daily (increase to 75 mg if needed)
     • Alternative: Gabapentin 900 mg/day (particularly if sleep disturbance is prominent)
     • For patients not on tamoxifen: Paroxetine 10-12.5 mg is another option

3. If first-line non-hormonal therapy fails:

   • Try alternative non-hormonal medication
   • Consider combination therapy under specialist guidance

Complementary Approaches (Limited Evidence)

• Vitamin E (800 IU/day) may provide modest benefit for mild symptoms 2, 6
• Black cohosh, soy products, and other botanical supplements have inconsistent evidence 5
• Clinical hypnosis has shown some benefit in small studies 5
• Lifestyle modifications: avoiding triggers (caffeine, alcohol), stress reduction, and exercise may help 1

The placebo effect in hot flash treatment is considerable (25% or more), suggesting that some patients may benefit from a trial of limited duration 1. Additionally, hot flashes may naturally decrease over time in some women, particularly those taking tamoxifen for early-stage breast cancer 1.