What are the treatments for hot flashes?

Management of Hot Flashes

For hot flashes, nonhormonal pharmacologic treatments including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, and clonidine should be considered first-line therapy, especially in women with a history of breast cancer or other contraindications to hormone therapy. 1

First-Line Pharmacologic Options

SSRIs/SNRIs

• Venlafaxine: 37.5-75 mg daily; reduces hot flash severity by approximately 60% 2
  • May have faster effect but less well tolerated than clonidine 1
  • Should be tapered when discontinuing to minimize withdrawal symptoms
  • Caution: Pure SSRIs (especially paroxetine) may interact with tamoxifen through CYP2D6 inhibition 1

Anticonvulsants

• Gabapentin: Start at 300 mg daily, titrate to 900 mg/day
  • Reduces hot flash severity score by 46% (vs 15% with placebo) 1
  • Side effects: Somnolence - particularly useful when given at bedtime for nighttime hot flashes 1
  • Preferred for women on tamoxifen due to lack of drug interactions

Antihypertensives

• Clonidine: 0.1-0.2 mg daily
  • Effective for reducing hot flash frequency and severity in women taking tamoxifen 1
  • Side effects: Sleep difficulties, dry mouth, fatigue, dizziness, nausea 1

Algorithm for Hot Flash Management

For Mild/Moderate Hot Flashes:

1. Start with nonpharmacologic approaches:

   • Lifestyle modifications: Avoid triggers (spicy foods, caffeine, alcohol)
   • Environmental modifications: Cool rooms, dressing in layers
   • Weight loss if overweight/obese 1
   • Consider vitamin E (800 IU/day) 1, 2
   • Consider acupuncture 1

2. If inadequate relief, add pharmacologic therapy:

   • For women without breast cancer: Any of the first-line options
   • For women on tamoxifen: Prefer gabapentin or venlafaxine (with caution)

For Severe Hot Flashes:

1. First-line: Gabapentin or SSRI/SNRI 1

   • Review efficacy and side effects at 4-6 weeks for gabapentin
   • Review efficacy and side effects at 2-4 weeks for SSRI/SNRI

2. If intolerant or ineffective: Switch to another nonhormonal treatment 1

3. If still inadequate relief and no contraindications: Consider hormonal options after thorough risk-benefit discussion

Nonpharmacologic Approaches

Evidence-Based Options:

• Acupuncture: Several studies show it may be equivalent or better than drug treatments 1
• Cognitive behavioral therapy (CBT) 1
• Hypnosis: One pilot study showed 59% decrease in daily hot flashes 1
• Paced respiration: Significant benefit shown in RCT 1

Limited Evidence Options (Category 2B):

• Yoga: May improve quality of life associated with menopause 1
• Vitamin E: Modest improvement but data limited and mixed 1
• Phytoestrogens/botanicals: Limited and mixed data 1
• Black cohosh: No benefit shown in randomized trials with breast cancer survivors 1

Hormonal Options (When Nonhormonal Approaches Fail)

Important Considerations:

• Contraindicated in women with history of hormonally mediated cancers 1
• Use with caution in women with coronary heart disease, hypertension, current smokers, or increased genetic cancer risk 1
• The HABITS trial showed increased risk of breast cancer recurrence with hormone therapy 1

Options When Appropriate:

• Estrogen alone (for women without a uterus)
• Estrogen plus progestin (for women with intact uterus)
• Prefer transdermal formulations (lower VTE and stroke risk) 1

Special Considerations

For Breast Cancer Survivors:

• Avoid hormonal therapies
• Gabapentin is particularly effective and safe 1
• If using SSRIs/SNRIs with tamoxifen, be aware of potential interactions 1
• Comprehensive menopausal assessment by a nurse practitioner has shown significant improvements in symptoms 1

Common Pitfalls to Avoid:

1. Using pure SSRIs (especially paroxetine) in women taking tamoxifen without considering drug interactions
2. Failing to taper SSRIs/SNRIs when discontinuing
3. Not recognizing that hot flashes often decrease in frequency and severity over time, even without treatment 1
4. Overlooking the significant placebo effect (up to 70%) in hot flash treatment trials 1

Remember that hot flashes typically improve over time, and the goal of therapy is to improve quality of life during the symptomatic period.