Q: What’s new in the world of hot flash therapies?
A: Not much, unfortunately.
If you’ve ever experienced a hot flash, you certainly know what it feels like. But let me quickly review the biology behind it: When you hit menopause and your estrogen level drops, major internal thermostat confusion ensues. This hormonal “short” sets off changes in the neurotransmitters of your brain causing the comfort zone of your thermostat to narrow. As a result, many stimuli (be they internal or external) upset it. And when set off, the confused thermostat “thinks” your body is too hot, so it sends instructions to several of your body’s systems in order to cool you down. Your heart may beat faster, blood vessels in your skin open to let heat escape and you perspire (remember evaporation helps heat escape) — hence, you flush and flash. In medical terms this is called a vasomotor menopausal symptom. (Which sounds equally uncomfortable.)
Hot flashes vary from mild (a “power flash” or simply, “Is it hot in here?”) to a drenching sweat that ruins your hair, makeup and clothes, adds an astounding redness to your face, and interrupts your daily living and your nighttime sleep. Women who undergo sudden and early menopause due to surgery, chemotherapy or radiation are more likely to suffer. Other women who are at high “flashing risk” include those who have a late perimenopause, are overweight, and those who are sedentary and/or smoke. (The last three may lead to a shorter flash experience as other health problems shorten their lives.)
Not every woman who goes through menopause experiences intense hot flashes, and a lucky 10 percent of menopausal women never experience even minor ones.
Although estrogen levels remain low for your entire menopausal life (unless you take hormone replacement therapy), hot flashes usually diminish with time. Unfortunately, 15 percent of women continue to experience hot flashes well into their 70s (or for the rest of their lives ... somehow the studies stopped at 70). Estrogen has been used for decades to treat hot flashes and there’s no question that estrogen hormone therapy works — it can reduce hot flashes by 90 percent or more, depending on the dose of hormones used and the severity of the hot flashes. It’s the only therapy to reach this level of effectiveness. High doses of another hormone, progesterone, have also been found to be somewhat effective. The data on natural progesterone as a cream or capsule is — to put it scientifically — “iffy.” More-conventional studies have been done on treatments like synthetic high-dose progestin pills (Megace), used to prevent recurrence of endometrial cancer, and Depo-Provera injections, which are used for birth control. Both of these options can, however, have side effects. There’s also an ongoing debate about the role of progestins in breast cancer development.
Many women can’t or won’t use hormones, so they and their doctors are anxiously looking at the over-the-counter products that have been promoted as “cures” for hot flashes. Although there are a plethora of studies that claim to have demonstrated the ability of these products to stop hot flashes, many are not controlled and most don’t give appropriate evidence of effectiveness. Know that proper randomized studies have shown that the placebo effect for these products can be as high as 50 percent. So when you see an over-the-counter supplement label that says it's “50 percent effective,” but doesn’t say how the success compares to placebo, it may very well be the placebo effect. In fact, overall results of studies of isoflavone extracts from plants (phytoestrogens) such as black cohosh, red clover and soy derivatives suggest that these compounds have little or no consistent effect “beyond placebo” on hot flashes.
There is data available, however, on hot flash reduction with some nonhormonal medications that are prescribed for conditions that are not menopausal. These prescription meds include:
Clonidine: This drug is used to treat high blood pressure. It lowers the sensitivity of your blood vessels (hence the dilation of surface vessels that occurs with the flush and flash), but it can cause side effects that include drowsiness, constipation, dry mouth and dizziness.
Antidepressants: They can be divided into two categories — SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). The brands that have been most tested include Paxil, Effexor and Celexa. A review of seven trials showed that these drugs led to a 15 percent or less decrease in the mean number of daily hot flashes compared with placebo. Indeed, I’ve had patients who have found these and other antidepressants to be quite helpful. But we know that depression and anxiety can increase hot flashes, so perhaps treating these conditions is more important than any direct effect of the medications on a woman’s internal thermostat. Of course I have to mention possible side effects, which include nausea, decreased appetite, mouth dryness, weight changes and sleepiness.
Gabapentin (Neurontin): This is an anti-epileptic drug that is also used to treat pain. When compared with a placebo, it caused half as many daily hot flashes. This drug can also lead to side effects, such as light-headedness, dizziness and swelling (edema).
The North American Menopause Society (NAMS) and the American College of Obstetricians and Gynecologists (ACOG) recommend that women with mild to moderate vasomotor symptoms try lifestyle changes with or without nonprescription remedies. This means avoidance of caffeine and alcohol, decreasing stress, wearing layered clothing, exercising and not smoking. They’re unsure whether nonprescription remedies help, but feel they can’t hurt (though women with a history of breast cancer probably shouldn’t be on a high dose of any phyto-estrogen or soy). For women with moderate to severe hot flashes, hormonal “interventions” are recommended. However, they suggest that women should use hormone therapy for as short a period of time as possible and take the lowest effective dose to treat their symptoms. They add that those who can’t or don’t want to take estrogen to control life-affecting hot flashes may want to consider an antidepressant.
Dr. Reichman’s bottom line: For severe hot flashes and night sweats, estrogen therapy works best. If you can’t or don’t want to take estrogen, there are prescription drugs that may work, but these are not without side effects, and they don’t work as well. Over-the-counter remedies have dubious effectiveness against hot flashes, but if your symptoms are mild, go ahead and give them a try.
Dr. Judith Reichman, the TODAY show’s medical contributor on women’s health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, “Slow Your Clock Down: The Complete Guide to a Healthy, Younger You,” which is now available in paperback. It is published by William Morrow, a division of .
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.