What are the pharmacotherapy options for vasomotor symptoms?

From the Guidelines

Hormone therapy is the most effective intervention for women with vasomotor symptoms, and it should be considered as the first-line treatment for eligible patients. According to the American Society of Clinical Oncology clinical practice guideline adaptation of Cancer Care Ontario guideline 1, hormone therapy is recommended for women with vasomotor symptoms, unless contraindicated, such as in hormone-sensitive breast cancer.

For women who cannot or prefer not to use hormone therapy, alternative options exist, including:

• Paroxetine, which can reduce hot flashes by 50-60% 1
• Venlafaxine, which is also effective in reducing hot flashes 1
• Gabapentin, which modulates calcium channels to reduce vasomotor symptoms 1
• Clonidine, which acts on central alpha-adrenergic receptors to reduce hot flashes, but may have adverse events such as hypotension, light-headedness, and headache 1

It is essential to individualize treatment based on symptom severity, medical history, contraindications, and patient preferences, with regular reassessment of benefits and risks. Estrogen therapy alone is recommended for women who have had a hysterectomy, as it has a more beneficial risk/benefit profile. Additionally, psychosocial counseling, such as cognitive behavioral therapy, and/or clinical hypnosis may provide a benefit and reduce vasomotor symptoms 1.

From the FDA Drug Label

2.1 Treatment of Moderate to Severe Vasomotor Symptoms due to Menopause

Start therapy with the 0.25 grams applied once daily on the skin of either the right or left upper thigh. Adjust the dose up to a maximum of 1.25 grams, as needed.

Vasomotor Symptoms Pharmacotherapy Options:

• Estrogen (TD): Start with 0.25 grams once daily, adjustable up to 1.25 grams as needed.
• The application surface area should be about 5 by 7 inches (approximately the size of two palm prints).
• Apply to the right or left upper thigh on alternating days to avoid potential skin irritation.
• Do not apply on the face, breasts, or irritated skin or in or around the vagina.
• Allow gel to dry after application before dressing.
• Do not wash the application site within 1 hour after applying estradiol gel 0.1%.
• Avoid contact of the gel with eyes.
• Wash hands after application 2, 2, 2.

From the Research

Vasomotor Symptoms Pharmacotherapy Options

• Hormone therapy is currently the only FDA-approved treatment for hot flashes, with recommendations to use the lowest dose for the shortest period necessary 3
• Non-hormonal options for vasomotor symptoms include:
  • Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, which is approved for moderate-to-severe postmenopausal vasomotor symptoms 4, 5
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) 6, 7
  • Gabapentin, which is effective for the relief of vasomotor symptoms 3, 6
  • Clonidine, a centrally acting non-hormonal therapy 3
• Emerging therapies for vasomotor symptoms include:
  • Estetrol 5
  • Oxybutynin 5
  • Neurokinin 3 (NK3) receptor antagonists 5
• Patient tailoring of treatment is key to managing symptoms of menopause, with physicians needing in-depth knowledge of the pharmacology of compounds to tailor therapy to the individual patient's characteristics and needs 6
• Non-hormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives for women who cannot use hormone therapy or have contraindications to using it 7