What are the treatment options for hot flushes?

Treatment of Hot Flushes

Start with lifestyle modifications and weight management, then escalate to SNRIs (venlafaxine) or gabapentin as first-line pharmacological options, reserving hormone replacement therapy for severe cases in appropriate candidates without contraindications. 1, 2

Algorithmic Approach to Management

Step 1: Non-Pharmacological Interventions (First-Line for All Patients)

Weight Management

• Women who lose ≥10% of body weight are significantly more likely to eliminate hot flush symptoms completely compared to those maintaining weight 1, 3
• This should be the primary recommendation for overweight or obese women 4

Lifestyle and Environmental Modifications

• Smoking cessation significantly improves both frequency and severity of hot flushes 1, 2
• Avoid specific triggers: spicy foods, caffeine, hot drinks, and alcohol 1, 2
• Environmental control: maintain cool room temperatures, dress in layers, use fans and cooling pillows 1, 2

Mind-Body Interventions

• Cognitive Behavioral Therapy (CBT) reduces the perceived burden and significantly improves hot flash problem ratings 1, 3
• Acupuncture has been shown equivalent to or better than venlafaxine or gabapentin in multiple studies, making it a legitimate first-line option 4, 1, 3
• Yoga may improve quality of life and vasomotor symptom domains, though effects on frequency are limited 4, 3

Step 2: Pharmacological Management (When Non-Pharmacological Measures Insufficient)

First-Line Pharmacological Options

SNRIs (Preferred)

• Venlafaxine: Start 37.5 mg daily, increase to 75 mg after one week if needed for greater symptom control 2
• Venlafaxine has faster onset than clonidine and is generally well-tolerated 4
• The NCCN recommends SNRIs as first-line pharmacological treatment 1

Anticonvulsants

• Gabapentin: 900 mg daily in divided doses provides optimal efficacy with 49% reduction in hot flash severity at 4 weeks and 46% at 8 weeks 2
• Particularly useful when given at bedtime due to somnolence side effects, helping patients with hot flash-disturbed sleep 4
• In head-to-head comparison, 68% of patients preferred venlafaxine over gabapentin, though efficacy was similar 4

SSRIs (Use with Caution)

• Low-dose paroxetine (12.5-25 mg daily) reduces hot flashes by 62-65% 2
• Critical caveat: Avoid paroxetine and other strong CYP2D6 inhibitors in women taking tamoxifen, as this interaction reduces tamoxifen efficacy 1, 2

Second-Line Options

• Clonidine: Can reduce hot flash frequency and severity but has more side effects (sleep difficulties, dry mouth, fatigue, dizziness, nausea) and slower onset than venlafaxine 4, 2
• Oxybutynin: Effective alternative for hot flush control 2

Step 3: Hormone Replacement Therapy (Most Effective but Restricted Use)

HRT remains the most effective treatment for vasomotor symptoms and is the only FDA-approved treatment for this indication 1, 5, 6

When to Consider HRT:

• Severe symptoms unresponsive to non-hormonal options 3
• No contraindications (no history of breast cancer, hormone-sensitive malignancy, thromboembolism, stroke) 2, 3
• Patient preference after thorough risk-benefit discussion 3

Critical Limitations:

• Use lowest effective dose 5
• Long-term use increases risk of stroke, pulmonary embolism, and invasive breast cancer with estrogen plus progestin 3
• Generally contraindicated in breast cancer survivors 1, 2
• Several guidelines suggest HRT is safe for up to 7 years in appropriate candidates 6

Special Population: Breast Cancer Survivors

Non-hormonal options are strongly preferred 1

Recommended Approach:

1. SNRIs (venlafaxine preferred) 1
2. Gabapentin 1
3. Lifestyle and environmental modifications 1
4. Acupuncture (shown equivalent or superior to pharmacological options in this population) 4, 1

Avoid:

• Systemic HRT is rarely given due to potential risks 1
• Strong CYP2D6 inhibitors (especially paroxetine) if on tamoxifen 1, 2

Common Pitfalls to Avoid

Drug Interactions

• Never prescribe paroxetine or other strong CYP2D6 inhibitors to women on tamoxifen 1, 2
• This interaction reduces tamoxifen's conversion to its active metabolite, potentially compromising cancer treatment efficacy

Inappropriate HRT Use

• Do not prescribe systemic HRT without thorough cardiovascular and thrombotic risk assessment, especially in postmenopausal women where risks are elevated 2
• Do not use HRT in breast cancer survivors or those with hormone-sensitive malignancies 2

Overlooking Medication-Induced Causes

• Identify if hot flushes are medication-induced (tamoxifen, aromatase inhibitors, GnRH agonists) before adding additional pharmacotherapy 2

Ineffective Treatments

• Phytoestrogens and botanicals have mixed or limited evidence 4, 1
• Vitamin E shows only marginal improvement with limited data 4, 1
• Black cohosh has no proven benefit, particularly in breast cancer survivors 4, 1
• Soy isoflavones are unlikely to provide significant relief, with only 3 of 8 studies showing modest improvement that disappeared after 6 weeks 3

Physical Activity Misconception

• While physical activity should be recommended for overall health benefits, evidence does not support its specific use for hot flash reduction 4, 3