What are the treatment options for hot flushes?

Treatment Options for Hot Flushes

For most women experiencing hot flushes, begin with weight loss (if overweight), smoking cessation, and trigger avoidance, then escalate to venlafaxine 37.5-75 mg daily or gabapentin 900 mg daily as first-line pharmacological options, reserving hormone replacement therapy for severe cases in women without contraindications. 1, 2

Initial Assessment and Risk Stratification

Before initiating treatment, rule out malignancy (particularly breast cancer) in postmenopausal women with new-onset hot flushes, as this presentation is atypical and warrants investigation. 2 Perform clinical breast examination and ensure mammography is current. 2 Identify any medications that could induce hot flushes, including tamoxifen, aromatase inhibitors, or GnRH agonists. 2

Non-Pharmacological Management (First-Line for All Patients)

Lifestyle Modifications

• Weight management: Women who lose ≥10% of body weight are significantly more likely to eliminate hot flush symptoms compared to those maintaining weight. 1, 3
• Smoking cessation: Quitting smoking significantly improves both frequency and severity of hot flushes. 1, 3
• Trigger avoidance: Eliminate hot drinks, alcohol, spicy foods, and caffeine, as these are documented thermogenic stimuli that induce hot flushes. 1, 2, 4
• Environmental modifications: Maintain cool room temperatures, dress in layers for quick cooling, use fans and cooling pillows, and wear breathable clothing materials. 1, 2

Mind-Body Interventions

• Cognitive Behavioral Therapy (CBT): Reduces the perceived burden of hot flushes and significantly improves hot flash problem ratings. 1, 2, 3
• Acupuncture: Safe and effective for managing vasomotor symptoms, with evidence showing equivalence or superiority to venlafaxine or gabapentin. 5, 1, 2, 3
• Yoga: May improve quality of life associated with menopause, including improvements in vasomotor symptoms, though effects on frequency may be limited. 5, 3

Pharmacological Management

First-Line Non-Hormonal Options

SNRIs (Preferred):

• Venlafaxine: Start at 37.5 mg daily, increase to 75 mg after one week if needed for greater symptom control. 1, 2 Venlafaxine may have faster effect but is less well-tolerated than clonidine. 5

SSRIs (Use with Caution):

• Paroxetine: Low-dose (12.5-25 mg daily) reduces hot flashes by 62-65%. 2
• Critical caveat: Avoid SSRIs that strongly inhibit CYP2D6 (particularly paroxetine) in women taking tamoxifen, as this interaction reduces tamoxifen efficacy. 1, 2, 3

Anticonvulsants:

• Gabapentin: Use 900 mg daily (divided doses) for optimal efficacy, with 49% reduction in hot flash severity at 4 weeks and 46% at 8 weeks. 2 Gabapentin causes somnolence, making it particularly useful when given at bedtime for patients with hot flush-disturbed sleep. 5

Antihypertensives:

• Clonidine: Can reduce hot flash frequency and severity but is generally less preferred than SNRIs or gabapentin. 5, 2 Side effects include sleep difficulties, dry mouth, fatigue, dizziness, and nausea. 5

Alternative Options:

• Oxybutynin: Effective alternative for hot flush control. 2

Hormone Replacement Therapy (Most Effective but Use Selectively)

HRT remains the most effective treatment for vasomotor symptoms but should be used cautiously due to significant risks. 1, 3 Long-term HRT use is controversial due to increased risk of stroke, pulmonary embolism, and invasive breast cancer with estrogen plus progestin. 3 HRT is generally contraindicated in women with history of breast cancer or hormone-sensitive malignancy. 2

Special Populations

Breast Cancer Survivors

Non-hormonal options are strongly preferred: 1

• SNRIs and SSRIs (avoiding CYP2D6 inhibitors if on tamoxifen) 1, 3
• Gabapentin 1
• Lifestyle and environmental modifications 1, 3
• Systemic HRT is rarely given due to potential risks 1

Comparative Effectiveness

Venlafaxine and gabapentin result in similar reductions in hot flash severity, though 68% of participants in one crossover study preferred venlafaxine over gabapentin (32%). 5

Treatments with Limited or No Evidence

Avoid or use with extreme caution:

• Phytoestrogens and botanicals: Mixed or limited evidence for effectiveness and safety. 5, 1, 3
• Vitamin E: Only marginal improvement with limited data. 5, 1, 2
• Black cohosh: Possible benefit in general population but no benefit demonstrated in breast cancer survivors. 5, 1, 2
• Soy isoflavones: Unlikely to provide significant relief, with only 3 of 8 studies showing modest improvement that disappeared after 6 weeks. 3 Substantial placebo effect (40-60% reduction) observed in control groups. 3

Common Pitfalls to Avoid

• Do not assume physiologic menopause in postmenopausal women with new-onset hot flushes without investigation. 2
• Do not use paroxetine or other strong CYP2D6 inhibitors if the patient is taking or may take tamoxifen. 1, 2
• Do not prescribe systemic HRT without thorough discussion of cardiovascular and thrombotic risks, particularly in older women. 2, 3
• Do not overlook medication-induced causes before initiating additional pharmacotherapy. 2
• Do not recommend physical activity specifically for hot flush reduction, as evidence does not support this use, though it should still be recommended for overall health benefits. 5, 3

Treatment Algorithm

1. All patients: Initiate weight loss (if overweight), smoking cessation, trigger avoidance, and environmental modifications 1, 2, 3
2. Persistent symptoms: Add CBT, acupuncture, or yoga 1, 2, 3
3. Moderate-to-severe symptoms requiring pharmacotherapy:
   • First choice: Venlafaxine 37.5-75 mg daily OR gabapentin 900 mg daily 1, 2
   • Alternative: Paroxetine 12.5-25 mg daily (if not on tamoxifen) OR clonidine 5, 2
4. Severe symptoms in eligible women: Consider HRT after thorough risk-benefit discussion 1, 3