Best Medication for Hot Flashes in a 67-Year-Old
Fezolinetant is the recommended first-line non-hormonal treatment for moderate to severe hot flashes in a 67-year-old woman, offering targeted action on hot flash pathophysiology with fewer side effects than alternatives. 1
First-Line Treatment Options
- Fezolinetant is recommended as first-line non-hormonal therapy for hot flashes, with significant improvements typically seen by week 4 1
- Fezolinetant avoids the 10-20% treatment withdrawal rate seen with SSRIs/SNRIs and doesn't require gradual discontinuation to prevent withdrawal symptoms 1
- Fezolinetant has a more targeted mechanism of action specific to hot flash pathophysiology and doesn't have potential drug interactions with tamoxifen through CYP2D6 inhibition 1
Alternative Medication Options
SSRIs/SNRIs
- Venlafaxine (37.5-75 mg daily) reduces hot flashes by approximately 60%, with significant declines in both frequency and severity compared to placebo 2, 3
- Paroxetine (10-20 mg daily) demonstrates 40-65% reduction in hot flash frequency and composite scores, with low-dose options (7.5-12.5 mg/day) showing improved tolerability 2, 4
- For women taking tamoxifen, avoid paroxetine and fluoxetine as they may decrease plasma levels of endoxifen (active tamoxifen metabolite) through CYP2D6 inhibition 2
- Citalopram and venlafaxine have minimal effects on tamoxifen metabolism and are better alternatives for breast cancer patients on tamoxifen 2
Gabapentin
- Gabapentin (900 mg/day) reduces hot flashes by 46-49% at 8 weeks compared to 15-21% with placebo 2
- Gabapentin has no known drug interactions and no absolute contraindications, making it suitable for women with complex medication regimens 2
- Side effects include somnolence, fatigue, dizziness, and unsteadiness, but these typically improve after the first week of treatment 2
- Gabapentin is the only non-hormonal treatment demonstrated to have equivalent efficacy to estrogen in treating hot flashes 2
Other Options
- Clonidine (oral or transdermal) shows modest efficacy but has limited utility due to side effects 3, 5
- Hormone therapy remains the most effective treatment for hot flashes (80-90% reduction) but carries risks including increased stroke and breast cancer risk 1, 6
Treatment Algorithm for Hot Flashes at Age 67
Assess severity and impact: If hot flashes are mild and don't interfere with sleep or daily function, consider non-pharmacological approaches with vitamin E (800 IU/day) 3
For moderate to severe symptoms:
- First choice: Fezolinetant (if available) 1
- Second choice (if fezolinetant unavailable or contraindicated):
- For women without breast cancer history: Venlafaxine starting at 37.5 mg daily, increasing to 75 mg after 1 week if needed 2
- For women with breast cancer on tamoxifen: Venlafaxine or citalopram (avoid paroxetine/fluoxetine) 2
- Alternative: Gabapentin 900 mg/day (particularly if SSRIs/SNRIs are contraindicated) 2
If initial therapy fails: Switch to an alternative medication class (e.g., from SSRI/SNRI to gabapentin or vice versa) 2, 7
Important Considerations
- Most medications show significant placebo effect (13-29%) in hot flash treatment, suggesting some women may benefit from a limited trial 2
- Hot flashes may decrease over time naturally, even in women receiving treatment 2
- Non-pharmacologic adjuncts like cognitive behavioral therapy, weight loss if overweight, smoking cessation, and acupuncture can help reduce hot flash symptoms 1