Treating Hot Flashes Without Hormones

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Treating Hot Flashes Without Hormones

• November 5, 2005
• Sarah Freitas MD

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Hot Flashes

• Sudden, inappropriate excitation of heat release
  mechanisms
• Brief sensation of warmth OR
• Waves of heat, drenching sweat, red flushing of
  the skin, increased heart rate
• Or anything in between.

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What causes hot flashes?

• Unknown
• Variation in hormone concentrations
• Effect on temperature regulation center in the
  brain

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Who gets hot flashes?

• Perimenopause - definition
• Hot flashes begin an average of 2 years before
  the cessation of menses
• 10 will continue greater than 10 years
• Incidence varies by geography, ethnicity,
  lifestyle

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What can we do about hot flashes?

• (Hormone replacement therapy)
• Lifestyle modification
• Non-prescription remedies
• Soy, botanicals, vitamins
• Non-hormonal prescriptions
• Anti-depressants, neurontin, anti-hypertensives

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Research points

• Placebo reduces hot flashes by 20-50
• For FDA studies must have 7-8 per day or 60 per
  week
• Most nonhormonal efficacy studies enrolled women
  with lower rates
• Hormone replacement therapy considered
  therapeutic standard (77-87 efficacy)

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Hot Flash Relief
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Bioidentical Hormones

• Same chemical structure as the substances your
  body makes.
• Your body produces 3 types of estrogen
  (estradiol, estrone, and estriol)
• FDA approved bioidentical hormones are part of
  traditional HRT
• Compounding pharmacies use agents that do not
  require FDA approval
• No evidence to suggest that bioidentical hormones
  reduce the known risks associated with
  conventional HRT

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Lifestyle modification

• Lower core body temperature
• Exercise
• Stop smoking
• Weight loss
• Relaxation techniques
• Paced respiration

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Diet and Nutrition

• Leafy, green vegetables
• Fish
• Soy products and other legumes
• Fiber
• Nuts and seeds

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Protein and Isoflavone Content of Soy-Based Foods
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Basic Nutrition Prescription for the Menopausal
Patient
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Nonprescription remedies

• Soy products
• Black cohosh
• Topical progesterone
• Vitamin E

• Dong quai
• Evening primrose oil
• St. Johns Wort
• Ginseng
• Licorice
• Chinese herbs

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Isoflavones phytoestrogens

• Soy-derived isoflavones May slightly reduce hot
  flashes
• Red clover (Rimostil, Promensil)
• Average dose 40-80 mg/day
• Potential for adverse effects seems minimal
• Long term safety has not been confirmed

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Estroven
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Black Cohosh

• Remifemin (20 mg tablet)
• Some studies show efficacy
• No known reports of serious adverse effects or
  drug interactions
• Moderate side effects are rare (GI upset)
• Effects of long term use unknown gt 6 months

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Evening Primrose Oil

• Approved in England for treatment of breast
  tenderness
• Only one RCT of hot flashes showed no benefit
  over placebo after 6 months
• Side effects - nausea, diarrhea

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St. Johns Wort

• Widely used in Europe for treatment of depression
• One study showed a decrease in menopausal
  symptoms when combined with black cohosh

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Dong-quai

• Traditionally used in Asia for amenorrhea,
  menstrual cramps and menopause symptoms
• Very few studies show no difference in hot
  flashes

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Other herbal remedies

• Ginseng
• Chinese Herb Mixtures
• Licorice
• Kava
• Green tea extracts
• Valerian root

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Vitamin E

• 400 IU twice daily
• Large RCT in breast cancer patients
• One hot flash reduction per person per day
• No acute adverse effects in doses up to 1,200 IU
  /day

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Topical progesterone

• Synthesized commercially from soybeans and wild
  yam
• No standardized dose or preparation
• Conflicting efficacy data
• No adverse effects reported in the literature
• General lack of safety and efficacy data

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Nonhormonal prescriptions

• Antidepressants
• Venlafaxine, Paroxetine, Fluoxetine
• Gabapentin
• Antihypertensives
• Clonidine
• Methydopa

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Venlafaxine

• Serotonin and norepinephrine reuptake inhibitor
  (SNRI)
• Up to 60 reduction in hot flashes
• Start with 37.5 mg can increase to 75 mg after
  one week
• SE somnolence, dizziness, nausea/vomiting,
  constipation, sexual dysfunction, increase blood
  pressure in 3

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Paroxetine

• Anti-depressant (SSRI)
• Reduced hot flashes 62-64 versus 38
• Start with 12.5 mg dose
• SE asthenia, sweating, nausea, decreased
  appetite, somnolence, insomnia, dizziness

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Fluoxetine

• SSRI
• 20 mg dose
• 20 reduction versus placebo
• Improvement not as great as with others
• Side effects and contraindications same as with
  paroxetine

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Gabapentin

• Mechanism unknown
• 45-54 versus 29-31 in placebo
• 300 mg 3 times daily
• SE dizziness, lightheadedness, peripheral
  edema. Also, somnolence, ataxia, and fatigue in
  seizure trials.

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Antihypertensives

• Clonidine
• 0.4 mg/day
• Oral decreased by 46
• Transdermal by 80
• Side effects limit use nausea, fatigue,
  headaches, dizziness, dry mouth

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Methyldopa

• 500 1,000 mg
• 65 versus 38 with placebo
• Contraindications MAO inhibitors, active liver
  disease.
• SE headache, asthenia, edema, and weight gain

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Options for Hot Flushing
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Clinical management

• Start with lifestyle modification
• Isoflavones 40-80 mg/day
• Black cohosh - 2 20mg tablets daily for 6 months
• Vitamin E 400 mg bid

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Hormonal therapies

• NAMS recommends considering lower-than standard
  doses (0.3 mg conjugated estrogens, 0.25-0.5 mg
  of 17B estradiol tabs, and 0.025 mg 17B estradiol
  patch)

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Non-hormonal therapies

• Start low dose venlaxafine (37.5 mg/day),
  paroxetine (12.5-25 mg/day), or fluoxetine (20
  mg/day)
• Gabapentin start 300 mg qHS. Can increase to
  bid, then tid at 3-4 day intervals
• Higher doses may have increased efficacy, but not
  yet studied
• Clonidine start 0.05 mg bid, or 0.1 mg patch.
  Taper off slowly

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Resources

• North American Menopause Society
• www.nams.org
• American College of Obstetrics and Gynecology
• www.acog.org
• www.WesternObGyn.com