Menopause Counseling: A Natural Approach to Treating Hot Flashes

When it comes to managing hot flashes, some women prefer natural treatments to prescription drugs. Pharmacists are in a unique position to counsel these patients.

Pharmacists Can Counsel Patients on the Proper Use of Natural Products

Hot flashes are a common problem for women getting close to or going through menopause. If you have ever had a hot flash, you know exactly what they are—feelings of sudden, intense heat all over your face, neck, and upper body that often leave you with a red face and feeling sweaty. A chilly feeling will often follow a hot flash. Some women will even experience nausea, a rapid heartbeat, dizziness, or a headache. These hot flashes last anywhere from seconds to minutes and are most commonly caused by changes in hormone levels (ie, estrogen) that occur with menopause. How can the pharmacist help? With OTC options available, patients will come into the pharmacy looking for relief—and answers to their questions about menopause.

Hot flashes can be bothersome, but there are several things that the patient can try. Wearing layered cotton clothing is useful; removing some of the clothing during a hot flash can help. Avoiding alcohol, coffee, and spicy foods and instead drinking cool drinks and using ice packs may also be helpful. Additionally, it is also recommended to avoid hot baths and/or showers. Some women find that exercise may help reduce the severity and/or the number of hot flashes they experience.

If these actions do not work, there are some medications and natural treatments available. Pharmacists are in a unique position to counsel their patients on these topics. Hormone replacement therapy and some drugs used to treat depression are available by prescription. However, some women choose to use more natural treatments such as soy, black cohosh, evening primrose oil, and dong quai that are available at the pharmacy without a prescription.

Soy, which comes from soybeans, contains phytoestrogens which are similar to natural estrogen in the body. Because soy acts like the estrogen found in the body, some women find it improves their hot flashes. However, some studies show that women taking sugar pills also experienced fewer hot flashes. In addition to improving hot flashes, most studies show that soy is able to increase bone density or at least slow the loss of bone density as a woman gets closer to and goes through menopause, reducing the risk for bone loss or osteoporosis. In patients with diabetes, soy may also help lower blood sugar levels. Additionally, soy has been shown to modestly decrease total cholesterol and bad cholesterol levels. Consuming 20 to 60 grams a day of soy protein has been recommended to improve hot flashes for women going through menopause. In addition to soybeans, soy can be found in soy milk, tofu, tempeh, sprouts, soy sauce, and soy flour. Soy is generally well tolerated, with possible side effects including nausea, bloating, and constipation.

Patients with a personal or family history of breast, endometrial or bladder cancers, kidney problems, or those who have ever had kidney stones, should speak with their doctors about taking soy products. Also, if the individual is taking blood thinners, such as warfarin, or the drug tamoxifen for the treatment of certain cancers, she should not take soy-containing products until speaking to her physician.

Like soy, black cohosh, also known as black snakeroot and bugbane, seems to have effects similar to estrogen in the body. Some studies looking at black cohosh show modest benefits in reducing the number of hot flashes, whereas others do not. Most of the studies have focused on 1 product in particular known as Remifemin (Enzymatic Therapy); it is unclear whether other products containing black cohosh are just as good in improving hot flashes. Certain patients should not use black cohosh, however. If the patient has a personal or family history of breast, uterine, or ovarian cancer, endometriosis, or fibroids, it is recommended that she avoid black cohosh, as it may worsen these conditions.

Some reports suggest that black cohosh may cause liver damage. If the patient has liver disease, she should not take black cohosh without speaking to her physician. Most side effects with black cohosh are mild and include stomach upset,headache, vaginal bleeding, and weight gain. Pharmacists should be aware that black cohosh may affect many drugs, especially some that are prescribed for high cholesterol, seizures, depression, and pain. When considering the use of black cohosh, do not confuse black cohosh with white or blue cohosh, as they are not the same thing.

Evening primrose oil is another natural product that some women may choose to use for treating hot flashes and about which they may come into the pharmacy with questions. However, most of the available studies do not find a large benefit from taking evening primrose oil for treating hot flashes.

Although evening primrose oil is generally well tolerated, it may increase the risk for bruising or bleeding. Patients with any conditions related to bleeding should not use evening primrose oil. Use should also be avoided if patients are within 2 weeks of undergoing or recovering from surgery or if they are using medications that are blood thinners or that slow clotting (Table). If the patient has a history of seizures, she should not use evening primrose oil, as it may increase the likelihood of seizures.

Dong quai, also known as Angelica sinensis, is another product that some women use to treat hot flashes. It is believed to work in the body like estrogen; however, most of the available studies show there is no difference in hot flashes between women taking dong quai either by itself or in combination with other natural products and women taking sugar pills. Because it may have effects like estrogen, women who have a history of breast, uterine, or ovarian cancers, endometriosis, or uterine fibroids should not use dong quai.

In addition, if patients are taking medications that stop or slow blood clotting, they should not take dong quai, as it may increase their chance for bruising and bleeding. Women who choose to use dong quai should also wear sunscreen when outside for long periods of time, especially if they have lighter skin, as the product can cause the skin to be very sensitive to the sun.

Finding the right treatment for hot flashes for your patient takes time and patience. It is important that they discuss these options with both their doctor and their pharmacist. Together, these health care professionals will be able to help the patient choose the best option to reduce the hot flashes associated with menopause.

Dr. Brown is assistant dean for academics and associate professor of pharmacy practice in Palm Beach Atlantic University's Lloyd L. Gregory School of Pharmacy in West Palm Beach, Florida.