Do you treat hot flashes due to menopause?

Treatment of Menopausal Hot Flashes

Yes, treat moderate to severe hot flashes due to menopause with a stepwise approach: start with lifestyle modifications and nonhormonal pharmacotherapy (gabapentin or venlafaxine as first-line), reserving hormone therapy for severe refractory symptoms in women without contraindications. 1, 2

Initial Assessment

Before initiating treatment, evaluate the frequency and severity of hot flashes and their impact on sleep and daily function. 3 Conduct a medication review to rule out drug-induced vasomotor symptoms and check thyroid function to exclude hyperthyroidism. 3

Stepwise Treatment Algorithm

Step 1: Lifestyle Modifications (First-Line for All Patients)

• Weight loss of ≥10% body weight is the priority intervention for overweight women, as this can eliminate hot flash symptoms entirely. 1, 2
• Smoking cessation substantially improves both frequency and severity of hot flashes, as symptoms are markedly worse in active smokers. 1, 2
• Environmental adjustments: dress in layers, maintain cool room temperatures, wear natural fibers, use cold packs intermittently, and avoid identified triggers (spicy food, alcohol, caffeine). 1, 2

Step 2: Nonhormonal Pharmacotherapy (First-Line Pharmacologic)

Gabapentin 900 mg/day at bedtime is the preferred first-line pharmacologic option, particularly if:

• The patient has concurrent sleep disturbance from hot flashes 1
• The patient is on multiple medications (no drug interactions) 1, 3
• The patient is taking tamoxifen 1
• Reduces hot flash severity by 46% compared to 15% with placebo, with efficacy equivalent to estrogen 1, 3

Venlafaxine 37.5 mg daily, increasing to 75 mg after 1 week is the alternative first-line option when:

• Rapid onset is prioritized 1
• Gabapentin is ineffective or not tolerated 1
• Reduces hot flash scores by 37-61% and is preferred by 68% of patients over gabapentin despite similar efficacy 1, 2

Paroxetine 7.5-12.5 mg daily is a second-line option:

• Reduces hot flash frequency and severity by 62-65% 1, 3
• Critical warning: Avoid paroxetine (and fluoxetine) in women taking tamoxifen due to CYP2D6 inhibition, which reduces conversion of tamoxifen to active metabolites 1, 2

Step 3: Adjunctive Nonpharmacologic Approaches

• Acupuncture is safe and effective, with some studies showing equivalence or superiority to venlafaxine or gabapentin. 1, 3
• Cognitive behavioral therapy (CBT) can significantly reduce the perceived burden of hot flashes, even if frequency remains unchanged. 1, 2
• Paced respiration training and structured relaxation techniques (20 minutes daily) show significant benefit. 1
• Clinical hypnosis showed a 59% decrease in daily hot flashes with significant improvement in quality of life. 1

Step 4: Hormone Therapy (Reserved for Severe Refractory Symptoms)

Menopausal hormone therapy (MHT) is the most effective treatment, reducing hot flashes by approximately 75% compared to placebo and achieving 80-90% symptom relief. 1, 2, 4 However, it should only be used when nonhormonal options fail and in women without contraindications. 1, 2

Preferred formulations:

• Transdermal estrogen (estradiol 50-100 µg daily) is preferred over oral preparations due to lower rates of venous thromboembolism and stroke. 1, 2
• Use the lowest effective dose for the shortest duration possible. 1, 5
• Women with an intact uterus require concurrent progestin; micronized progestin is preferred over medroxyprogesterone acetate due to lower rates of VTE and breast cancer risk. 1

Absolute Contraindications to Hormone Therapy

MHT is contraindicated in women with: 1, 2, 5

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

Special Population: Breast Cancer Survivors

For women with breast cancer history, systemic hormone therapy is contraindicated. 2 The treatment hierarchy includes: 1, 2

1. Lifestyle modifications (weight loss, smoking cessation)
2. SNRIs (venlafaxine) or gabapentin as first-line pharmacologic options
3. SSRIs (avoiding paroxetine if on tamoxifen)
4. Acupuncture or CBT

Do not screen patients for CYP2D6 despite theoretical concerns about SSRI-tamoxifen interactions, as negative impact on breast cancer outcomes has not been conclusively demonstrated. 1, 2

Efficacy Timeline and Monitoring

• Review efficacy at 2-4 weeks for SSRIs/SNRIs and 4-6 weeks for gabapentin. 1
• If intolerant or ineffective, switch to another nonhormonal agent. 1
• Recognize the robust placebo response (up to 70% in some studies) when evaluating treatment efficacy. 1
• Many hot flashes improve spontaneously over time with ongoing treatment. 1

Common Pitfalls to Avoid

• Never use paroxetine or fluoxetine in women taking tamoxifen due to CYP2D6 inhibition. 1, 2
• Avoid vitamin E as monotherapy for severe symptoms; doses >400 IU/day are linked to increased all-cause mortality. 1, 3
• Black cohosh is not recommended due to lack of efficacy in randomized trials and reports of liver failure. 1
• Taper SSRIs/SNRIs gradually on discontinuation to minimize withdrawal symptoms; never stop abruptly. 1
• In older adults, estrogen therapy is strongly discouraged due to increased stroke risk, venous thromboembolism risk, and breast cancer risk. 3

Important Note on USPSTF Recommendation

The USPSTF recommendation against hormone therapy 6 applies only to the primary prevention of chronic conditions (cardiovascular disease, osteoporosis, dementia) in postmenopausal women. It explicitly does not apply to women considering hormone therapy for the management of menopausal symptoms such as hot flashes. 6 This distinction is critical: hormone therapy remains an appropriate treatment option for bothersome vasomotor symptoms when used at the lowest effective dose for the shortest duration. 1, 2, 4