Non Hormonal Treatment of Hot Flashes in Menopause
Menopause is the permanent cessation of a woman’s menstrual cycle. The average age at the onset of menopause is approximately 51 years. Considering that the average life expectancy of women in the United States is 81 years, women may be postmenopausal for more than one-third of their lives. Hot flushes and night sweats are the most common menopausal symptoms, and there is evidence these symptoms may last for 4 to 10 years, peaking in the year around the final menstrual period and with an average duration of 7 years in some studies. Around 25% of women experience problematic vasomotor symptoms (VMS) that reduce quality of life, requiring treatment in severe cases.
Estrogen has been used as a hormonal supplement in the treatment of menopausal symptoms for over 60 years, and estrogen therapy is the most effective treatment for VMS in postmenopausal women. Estrogen therapy, however is contraindicated for treatment of VMS in women with a history of breast cancer, CHD, previous venous thromboembolic events, transient ischemic attack, or stroke; unexplained vaginal bleeding; high-risk endometrial cancer; and active liver disease. For this reason, non-hormonal approaches have been considered to treat VMS in postmenopausal women.
Non-hormonal prescription therapies including selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), gabapentin, and clonidine have been tested in randomized placebo-controlled trials, and shown to be effective. The North American Menopause Society (NAMS) has published recommendations based on their review of evidence regarding the non-hormonal management of menopause-associated VMS. They reported that cognitive behavioral therapy and clinical hypnosis may be effective nonprescription therapies for the reduction of VMS, and summarized that there is suggestive evidence for the efficacy of SSRIs, SNRIs, gabapentinoids, and clonidine as non-hormonal therapies for VMS. However, some SSRIs interfere with tamoxifen metabolism. While paroxetine has been shown to have a strong interaction, venlafaxine and gabapentin are not known to interact with tamoxifen. Gabapentin could be used for the treatment of VMS in postmenopausal women with contraindications to HT, especially patients with breast cancer who are taking tamoxifen as endocrine therapy or for high-risk women who are taking tamoxifen to reduce their risk of breast cancer.