Alternatives to HRT for the Treatment of Hot Flashes

Ms. Wick is a senior clinical researchpharmacist at the National CancerInstitute, National Institutes ofHealth, Bethesda, Maryland. Theviews expressed are those of theauthor and not those of any governmentagency.

During perimenopause, mostwomen experience hot flashesof varying frequency andintensity. When they occur more than afew times daily, or even hourly, theseepisodes can be quite disruptive andare often accompanied by vaginal dryness,decreased libido, forgetfulness,difficulty concentrating, and nightsweats that disturb sleep.

Although estrogen and progesteroneare used to treat hot flashes, theWomen's Health Initiative (WHI) studyfound that routine use of these therapiesincreases some specific risks.^1-3Many women who had used estrogenfor hot flashes panicked and stoppedtheir medications abruptly, and nowthose who might benefit from hormonereplacement therapy (HRT) aresearching for alternatives. For this reason,pharmacists need to be fullyaware of self-care and medical treatmentoptions that can help womenmanage menopausal symptoms.

Hot flashes usually subside over ayear or 2 after menopause, but in theinterim, these sudden sensations ofintense heat, frequently accompaniedby profuse sweating and facial or bodyflushing, are intrusive and embarrassing.The chill that follows can be terriblyuncomfortable. Stress, heavy alcoholuse, and cigarette smoking seem toexacerbate hot flash frequency andintensity. Sufferers may report anxiety,irritability, or mild to severe heart palpitations.Hot flashes can be especiallydifficult for women who cease menstruatingabruptly from chemotherapy,antiestrogen treatment for breast cancer,or surgical removal of the ovaries.⁴

When to Treat

If hot flashes are mild or infrequent,treatment is usually unnecessary.Women who suffer moderate to severeor frequent hot flashes often look forrelief, and some lifestyle choices mayhelp. Breathing exercises, for example,have been shown to reduce hot flashesand emotional symptoms significantly^5,6(Table).

If hot flashes are severe and disruptive,the patient may ask for medication.Short-term HRT—at the lowestdose needed for the shortest possibletime—remains the most effectivetreatment. The WHI study linked HRT toan increased risk of breast cancer, cardiovasculardisease, stroke, venousthromboembolism, and dementia. Italso confirmed estrogen's protectiverole in bone health.^1-3

Pharmacists need to know thattreatment of menopausal symptomssuch as hot flashes was not a WHI endpoint; WHI was designed to determineif HRT prevents chronic diseases likeheart disease and osteoporosis. Theaverage age of WHI participants was63, or about 12 years postmenopausal.Since the study was published, it hasbecome more evident that dependingon the patient's age, hormone therapyhas different benefits and risks.^7-11

Before menopause, estrogen?progestinbirth control pills can amelioratehot flashes and other perimenopausalsymptoms by preventing fluctuatinghormones. Perimenopausal womenwho smoke, have diabetes, or have apersonal or family history of cardiovasculardisease or breast cancer shouldavoid using estrogen for hot flashrelief.^12-14

Women who have an intact uterusshould not take unopposed estrogen;they must also take progesterone.Unopposed estrogen increases risk ofendometrial malignancy.

Nonhormonal Alternatives

Interest in nonhormonal therapies ishigh at this time. Selective serotoninreuptake inhibitor (SSRI) antidepressantmedications can reduce the numberand severity of hot flashes;researchers believe their ability toinhibit serotonin reuptake may significantlyreduce vasomotor symptoms ofmenopause. SSRIs are more likely towork if the patient's main complaintsare hot flashes, irritability, or moodswings. Pharmacists need to providethe standard guidance about sideeffects, counsel patients to take thesemedications early in the day, especiallyif insomnia is a problem, and adviseagainst abrupt discontinuation.^15-20

Numerous studies have been conductedusing clonidine, which mayreduce peripheral vascular reactivity;however, many of them are older,small, or of poor design.^21-25 To date, thestrongest evidence of clonidine's utilityis in women with tamoxifen-inducedhot flashes.²¹,²⁵ Because hot flashes inwomen with breast cancer are commonand pose a management problem(estrogen therapy is contraindicated,and tamoxifen interacts with manydrugs), this is an important option.

Black cohosh may reduce or preventhot flashes, depression, and anxiety,^26,27 but a large, randomized, controlled,placebo-blinded study (N = 351)could not confirm its efficacy in eitherpremenopausal or postmenopausalwomen.²⁸ (This same study found nobenefit in soy supplements.) Althoughmost of this herb's side effects are mildand transient (gastrointestinal upset orrash), numerous studies and casereports have documented blackcohosh's rare but potential hepatotoxicity,which can cause death.^29-33

Researchers recently have had encouragingpreliminary results with 49 gof crushed flaxseed daily in a small study(N = 30) of perimenopausal women,noting reductions of >50% in hot flashseverity and frequency. Mild or moderateabdominal distention was common,as was mild diarrhea. This dietary therapyneeds more study to determine if itis more effective than placebo.³⁴

Conclusion

Although the number of alternativetreatments for hot flashes is increasing,hormonal therapies are still themost effective. Pharmacists need to befamiliar with the risks and benefits ofhormonal and nonhormonal therapiesand aware of the OTC products womenmay use to find relief.

Clear communication about treatmentrisks and benefits, individualizationof treatment to meet patient needsand beliefs, and careful follow-up canhelp women find potentially effectivetherapy. The good news: Since the WHIresults were published, researchershave documented a significant decreasein prescriptions for HRT, but a significantlyhigher percentage of prescriptionfilling. This seems to mean thatwomen who choose HRT do so withgreater certainty in their choice.³⁵

References

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