What are the treatments for hot flashes associated with menopause?

Treatment of Menopausal Hot Flashes

For women without contraindications to hormone therapy, estrogen remains the most effective treatment, reducing hot flashes by approximately 75-90%, but nonhormonal options including SSRIs/SNRIs, gabapentin, and clonidine should be considered first-line for most patients, particularly those with breast cancer history or other contraindications to estrogen. 1, 2

Treatment Algorithm by Severity

Mild to Moderate Hot Flashes

• Start with lifestyle modifications: weight loss of ≥10% body weight, smoking cessation, limiting alcohol intake, wearing natural fibers, and using cold packs intermittently 1, 3
• Vitamin E 800 IU daily has limited efficacy but is reasonable for patients requesting "natural" treatment, though doses >400 IU/day are linked to increased all-cause mortality 3
• Clonidine can reduce hot flash frequency and severity with slower onset than venlafaxine but better tolerability 1, 3

Severe Hot Flashes

First-line nonhormonal pharmacologic options (preferred by NCCN guidelines) 3, 1:

• SSRIs/SNRIs: Paroxetine 7.5 mg daily reduces frequency, severity, and nighttime awakenings 3, 1. However, avoid paroxetine in women taking tamoxifen due to CYP2D6 inhibition that blocks conversion of tamoxifen to active metabolites, though evidence on clinical impact is conflicting 3. Venlafaxine is often preferred over gabapentin (68% vs 32% patient preference) and reduces hot flashes by approximately 60% 1, 4

• Gabapentin 900 mg/day decreases hot flash severity score by 46% compared to 15% with placebo, particularly useful when taken at bedtime for patients with sleep disturbance 1, 3

• Review efficacy at 2-4 weeks for SSRIs/SNRIs and 4-6 weeks for gabapentin; if intolerant or ineffective, switch to another nonhormonal agent 3

Nonpharmacologic Approaches

• Acupuncture is safe and effective, with some studies showing equivalence to or superiority over venlafaxine or gabapentin 1
• Paced respiration training and structured relaxation techniques (20 minutes daily) show significant benefit in RCTs 3
• Cognitive behavioral therapy (CBT) may reduce perceived burden of hot flashes 1

Hormone Therapy Considerations

Estrogen is the gold standard, reducing hot flashes by 80-90%, but should be reserved for specific situations 2, 4, 5:

When to Use Estrogen

• Start at lowest effective dose (typically 1-2 mg daily estradiol) for the shortest duration necessary 2
• Transdermal formulations are preferred due to lower rates of venous thromboembolism and stroke compared to oral formulations 1
• Women with intact uterus must receive concurrent progestin to reduce endometrial cancer risk; micronized progestin is preferred over medroxyprogesterone acetate due to lower VTE and breast cancer risk 1, 2
• Reevaluate every 3-6 months to determine if treatment is still necessary 2

Absolute Contraindications to Estrogen 3, 2

• History of hormone-related cancers (breast, uterine)
• Abnormal vaginal bleeding (undiagnosed)
• Active or recent thromboembolic events
• Active liver disease
• Pregnancy

Important Safety Warnings

• Combined estrogen/progestogen therapy increases breast cancer risk when used >3-5 years 1, 6
• Increases risk of stroke and venous thromboembolism 1, 2
• May increase risk of dementia in older women 2
• Initiation many years after menopause is associated with excess coronary risk, whereas initiation soon after menopause is not 7

Special Populations

Breast Cancer Survivors

• Avoid estrogen and tibolone as they may increase recurrence risk 3
• Venlafaxine, paroxetine (with caution if on tamoxifen), and gabapentin are effective for reducing frequency and severity of hot flashes 3
• Consider switching between aromatase inhibitors and tamoxifen if one causes intolerable symptoms, as there are modest differences in menopausal side effects 3
• Black cohosh is not recommended due to lack of efficacy and reports of liver failure 3

Persistent Severe Symptoms Despite Nonhormonal Therapy

• For women with advanced breast cancer or those with severe symptoms affecting quality of life, estrogen may be considered after fully informed discussion of risks, with the decision ultimately resting with the patient 3

Common Pitfalls to Avoid

• Do not recommend acupuncture for breast cancer survivors with prior axillary surgery on the affected arm 3
• Do not advise patients to simply "relax" without structured guidance; adequate training in relaxation techniques is essential for efficacy 3
• Do not use complementary therapies like black cohosh, multibotanicals, or soy as published data do not support efficacy and safety is not established 3