What are the treatment options for hot flashes?

Treatment Options for Hot Flashes

The most effective treatments for hot flashes are nonhormonal pharmacologic options including SSRIs/SNRIs (venlafaxine, paroxetine, citalopram) and gabapentin, with hormone therapy reserved for cases where these options fail or are contraindicated. 1

First-Line Nonhormonal Pharmacologic Options

SSRIs/SNRIs

• Venlafaxine (SNRI) has shown significant reduction in both hot flash frequency and severity at doses of 37.5-75 mg, with 75 mg providing incremental improvement over lower doses 1

  • Recommended starting dose: 37.5 mg, with increase to 75 mg after 1 week if greater symptom control is desired 1
  • Side effects include dry mouth, reduced appetite, nausea, and constipation, which increase with higher doses 1

• Paroxetine (SSRI) significantly reduces hot flash composite scores by 62% at 12.5 mg daily and 65% at 25 mg daily 1

  • Optimal dose is 10 mg or 12.5 mg controlled release to minimize side effects 1
  • CAUTION: Paroxetine should be avoided in women taking tamoxifen as it may interfere with tamoxifen metabolism through CYP2D6 inhibition 1

• Citalopram and fluoxetine have also shown efficacy, with fluoxetine decreasing hot flash composite scores by 50% versus 36% for placebo 1

  • Women who don't respond to venlafaxine may respond to citalopram 1

Gabapentin

• Gabapentin at 900 mg/day reduced hot flash severity by 46-49% (versus 15-21% with placebo) 1
  • Lower dose (300 mg/day) showed less efficacy with reductions of 31-33% 1
  • Side effects include somnolence and fatigue 1
  • Acts through central temperature regulatory centers 1

Other Pharmacologic Options

• Clonidine (oral and transdermal formulations) reduces hot flashes in a dose-dependent manner 1
  • Side effects include dry mouth, constipation, and drowsiness 1
  • Less effective than newer options like SSRIs/SNRIs and gabapentin 2

Non-Pharmacologic Approaches

• Lifestyle modifications that may help manage hot flashes include: 1

  • Avoidance of caffeine and alcohol
  • Regular exercise
  • Relaxation training
  • Maintaining cool ambient temperature

• Vitamin E may decrease frequency and severity of hot flashes, but clinical trials show only modest improvement compared to placebo 1

• Black cohosh has not shown significant differences compared to placebo in double-blinded, randomized controlled trials 1, 3

• Other complementary approaches (herbal supplements, acupuncture) lack strong supporting evidence 1, 3

Important Considerations

• The placebo effect in hot flash treatment is considerable (typically 25% or more), suggesting that a trial of limited duration might help some patients 1

• Not all women who experience hot flashes require medical intervention; decision to treat should consider the impact on quality of life 1

• Hot flashes may decrease over time, as shown in studies of women receiving tamoxifen for early-stage breast cancer 1

• When using SSRIs/SNRIs, gradual tapering is recommended when discontinuing to prevent withdrawal symptoms, particularly with short-acting agents like paroxetine and venlafaxine 1

• For women taking tamoxifen, venlafaxine and citalopram are preferred over paroxetine and fluoxetine due to minimal effects on tamoxifen metabolism 1

Treatment Algorithm

1. Assess severity and impact on quality of life

   • For mild symptoms not affecting sleep or daily function: start with lifestyle modifications and vitamin E (800 IU/day) 2
   • For moderate to severe symptoms: proceed to pharmacologic options

2. First-line pharmacologic therapy:

   • Venlafaxine 37.5 mg daily, increase to 75 mg if needed after 1 week 1
   • OR Gabapentin 300 mg daily, titrate to 900 mg daily in divided doses 1
   • For women on tamoxifen: avoid paroxetine and fluoxetine; use venlafaxine or citalopram 1

3. If first-line therapy fails:

   • Try alternative SSRI/SNRI or switch from SSRI/SNRI to gabapentin or vice versa 1
   • Consider clonidine as a third-line option 2

4. For women with no contraindications who fail to respond to nonhormonal options:

   • Consider hormone therapy at lowest effective dose 4, 5
   • Note that hormone therapy is contraindicated in women taking tamoxifen 1