Strategies for managing hot flashes

,

Applied Evidence

Strategies for managing hot flashes

J Fam Pract. 2011 June;60(6):333-339

By

Ghufran A. Jassim, MD

Hormone therapy—at the lowest possible dose for the shortest period of time—remains the best option for menopausal women with moderate to severe vasomotor symptoms.

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References

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20. Sare GM, Gray LJ, Bath PM. Association between hormone replacement therapy and subsequent arterial and venous vascular events: a meta-analysis. Eur Heart J. 2008;29:2031-2041.

21. Bath PM, Gray LJ. Association between hormone replacement therapy and subsequent stroke. BMJ. 2005;330:342.-

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24. Wren BG. Transdermal progesterone creams for postmenopausal women. Med J Aust. 2005;182:237-225.

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27. Kenemans P, Bundred NJ, Foidart JM, et al. Safety and efficacy of tibolone in breast-cancer patients with vasomotor symptoms. Lancet Oncol. 2009;10:135-146.

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PRACTICE RECOMMENDATIONS

• Use hormone therapy (HT) at the lowest effective dose and for the shortest duration possible (preferably ≤5 years) in women for whom the potential benefits outweigh the potential risks. A

• Counsel patients that the effectiveness of phytoestrogens (soy), exercise routines, yoga, acupuncture, vitamin E, evening primrose oil, and other herbal preparations has not been established. B

• When HT is refused or contraindicated by a patient’s risk profile, consider antidepressants (selective norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors), gabapentin, or clonidine. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Hot flashes are the most prevalent and most bothersome symptoms of the menopausal transition and the leading cause for seeking medical attention during that period of a woman’s life.¹ They may last for a few seconds or for several minutes and may occur as frequently as every hour to several times per week. On average, women experience hot flashes for a period of 6 months to 2 years, but the symptoms may last up to 10 years or more.^2,3

Hot flashes have been reported by up to 70% of women undergoing natural menopause, and by almost all women undergoing surgical menopause.⁴ For many women, these symptoms are mild and can be managed with reassurance and counseling. For others, the symptoms are severe, overwhelming, last for many years, and impair the quality of life.

According to a community-based survey of 16,000 women, hot flashes occur most often in late perimenopause and among those with a body mass index ≥27. Hot flashes are also more common among African Americans and women who are less physically active and have a lower income.⁵

Since the publication of the Women’s Health Initiative study in 2002 raised concerns about the long-term safety of hormone therapy (HT), nonhormonal remedies have emerged as potential alternative treatments.^6,7 A wealth of evidence has accumulated on the efficacy and safety of these, and various other approaches to the management of hot flashes. This review will summarize that evidence to help you provide optimal care and assist patients in making informed choices about their treatment.

Hormone replacement therapy

HT, given as estrogen alone in women without a uterus or estrogen plus progestin in women with a uterus, is the most studied and most effective therapy for vasomotor symptoms attributable to menopause. Data from one Cochrane review showed a significant reduction in the frequency of weekly hot flashes for oral estrogen compared with placebo, with a weighted mean difference (WMD) of -17.92 (95% confidence interval [CI], -22.86 to -12.99).⁸ This was equivalent to a 75% reduction in frequency (95% CI, 64.3-82.3) for HT relative to placebo. Results were similar for both opposed and unopposed estrogen regimens.⁸

FAST TRACK

Ten years after the end of the Women’s Health Initiative, follow-up data show participants in the estrogen-only arm continued to exhibit a decreased risk of breast cancer.

Transdermal vs oral therapy. Another review compared oral estradiol, transdermal estradiol, and placebo in terms of reduction of hot flash frequency or severity, or both.⁹ The review revealed a pooled WMD in hot flashes of -16.8 per week (95% CI, -23.4 to -10.2) for oral estradiol and -22.4 per week (95% CI, -35.9 to -10.4) for transdermal estradiol. Results were similar for opposed and unopposed estrogen regimens.⁹

Transdermal delivery of estrogen as patches, gels, and sprays delivers unmetabolized estradiol directly to the blood stream, so that lower doses can achieve similar efficacy to doses administered orally.¹⁰ Thus, the transdermal route would be in keeping with current guidelines to prescribe the lowest effective dose that relieves symptoms. Emerging research should provide more insight regarding safety and the potential for fewer health risks with transdermal HT compared with oral therapy.

Best way to discontinue? When HT is discontinued, hot flashes may return—sometimes immediately, sometimes after a few months. No evidence-based guidelines exist on the best way to discontinue HT with the least recurrence and severity of hot flashes. No optimal tapering regimen (either by dose or number of days per week that HT is taken) has yet been described in any studies, nor have any randomized controlled trials (RCTs)revealed a significant difference between tapered or abrupt discontinuation.^11,12

FAST TRACK

Progesterone alone reduces frequency of hot flashes, but withdrawal bleeding and concerns about breast cancer risk limit its usefulness.

The breast cancer connection. The relationship between HT and breast cancer has generated considerable controversy. In the Women’s Health Initiative (WHI) trial, which included participants on estrogen-only and estrogen plus progesterone regimens, an overall increased risk (hazard ratio [HR]=1.26; 95% CI, 1.00-1.59) was reported. The increased risk fell short of statistical significance, and varied with the duration of exposure.⁶