Guest Author - Denise Howard, M.D., M.P.H.

Hot flashes are the major reason women going through the menopause seek medical care. They are not life threatening and are not a sign of a medical disorder. They can however interfere with the quality of life. The frequency of the flashes can interfere with daily functioning. The flashes are distracting, they can cause sleep deprivation and produce anxiety. They can last from a few months to years thus the severity and persistence of the flashes typically results in the need for medical intervention. Options for treatment include hormonal and nonhormonal medication as well as behavioral and nonmedical therapies.

Traditional hormone replacement therapy (HRT) is the “gold standard” for treating hot flashes. It reduces hot flashes by 80-90%. Hormone replacement therapy entails estrogen only therapy in women who have undergone a hysterectomy and combined estrogen and progestin in women whose uteri are still in place. The problem with HRT is the potential risk and side effects. Side effects include weight gain, swelling, breast tenderness and uterine bleeding. Risks include blood clots in the deep veins that could lead to an embolus, heart attack, stroke and breast cancer. Most of these problems are attributable to the estrogen.

Progestin only treatment is an option for women who can’t take estrogen or desires an estrogen free treatment. Megace, a progestin, has been proven to decrease the incidence of flashes by 75-80%. There are some findings that suggest Depoprovera may also be helpful. Progestin only therapy has its’ problems including symptoms of depression and possible bone loss with long-term therapy.

Nutritional supplements such as black cohosh, vitamin E and soy proteins have some reported benefits. Black cohosh is available in a formulation called “Remifemin” which is available over the counter in many pharmacies and grocery stores. 800 international units of Vitamin E daily are recommended for the management of mild hot flashes. Finally soy extracts or increasing the amount of daily soy intake is an option for hot flash management.

Tibolone is a synthetic hormone that has estrogenic, progestational, and androgenic effects. It is being studied in Europe and has shown potential for the management of vasomotor symptoms. In addition to decreasing hot flashes it also decreases vaginal dryness and some of the urinary symptoms that accompanies menopause.

Clonidine is an older therapy used for the treatment of hot flashes. It is an antihypertensive agent. Even though it is helpful the side effects make it an unattractive option given the availability of other drugs.

Selective serotonin-reuptake inhibitors such as Venlafaxine, Fluoxetine, and Sertraline have been shown to reduce flashes by 37-61% compared to placebo. These drugs are approved for the treatment of depression and thus are also helpful for the mood disturbance that some women experience when going through menopause.
Gabapentin, a medication used for seizures and neuropathic pain, has been shown to decrease flashes by 46-49%. The recommended dose is 900 mg a day.

Behavioral therapies include lifestyle changes that make the flashes less severe. Dressing in layered clothing so they can be easily removed, lowering the room temperature, and drinking cool beverages are suggested strategies. Paced respirations or slow deep breathing can reduce flash frequency by approximately 50%. Stress relief and relaxation therapy are also helpful.

There are many options for managing hot flashes. Hormonal treatment is one option but many other alternatives exist. It is important to work with your health care provider to develop a plan that is right for you.