Women are either lucky or
unlucky when it comes to the hallmark symptom of the menopause, the hot flash.
As previously described in an earlier blog, the vasomotor symptoms (VMS) of
menopause, hot flashes by day and night sweats in bed, follow the rule of
quarters. One quarter of women escape completely, one quarter have mild
symptoms, one quarter moderate, and one quarter are truly disabled.
By far the most effective
medication for treating VMS is of course estrogen. But symptoms are not always
severe enough to justify a prescription, or there may be a medical reason making HT not
advisable, or a woman may just not be comfortable with the idea of taking
Before starting any therapy,
it is essential to consider the frequency and severity of VMS and their impact
on quality of life and daily living. Unless the hot flashes are bothersome, why
take any treatment?
TREATMENT OPTIONS FOR
VASOMOTOR SYMPTOMS – FROM THE LEAST INVASIVE TO THE MOST INVASIVE:
1. Try relaxation techniques –
meditation, yoga, or gentle massage are examples.
2. Healthy diet, and regular aerobic
and muscle strengthening exercise will improve fitness and enhance sleep.
3. Smokers must be advised to stop
immediately. Absorbed chemicals from smoking lowers estrogen levels and trigger
flashes, and obviously that is the least of the bad news associated with this
4. There are a number of hot flash
triggers that can be avoided including spicy foods, hot drinks, and caffeine.
5. Dressing in layers, keeping the
bedroom cool, and using a fan may be helpful.
6. Women can be taught to try a
technique called paced respiration.
As a flash starts, immediately start deep, slow, abdominal breathing.
7. There are some nonprescription
therapies that work better than a placebo, but not as well as hormones, and
have a role in management of mild symptoms. These include soy isoflavones and flaxseed.
A more active derivative of soy isoflavones, called equol, is being studied and may be more effective.
8. Then there is hormone therapy
(HT). The risks and benefits will be discussed in detail in upcoming blogs. The
efficacy is not disputed, and in otherwise healthy women, the risks of less
than 5 years’ use are really quite low. I can tell you that breaking news on
new recommendations is imminent from leading USA and international
9. Finally, particularly for women
who cannot or will not take hormones, there are other prescription drug
remedies that can be prescribed “off-label.” This means that the FDA has
approved them for a different indication and not for treatment of VMS. These
unfortunately are not as effective as hormones, giving about 65% relief
compared to the 95% for HT.
· Antidepressant drugs – so called
selective serotonin reuptake inhibitors (SSRI) and selective serotonin norepinephrine reuptake inhibitors (SNRI).
Well-known names include Prozac and Effexor. There is no research about the use
of these drugs on a long-term basis in women who were not depressed, so I would
urge caution in their use. What happens if a woman who was not depressed took
these drugs for some period of time and then stopped? Would she become
depressed? We just do not know.
· Anticonvulsant drugs – gabapentin is
the name of the one used off-label. It has side effects including sleepiness,
so could help with night sweats, being best suited to women for whom sleep
disruption is especially bothersome. The FDA is currently reviewing approval of
gabapentin for VMS.
and hypnotics –include barbiturates and a hypnotic called eszopiclone, their role being best for
night sweats for obvious reasons
· Antihypertensive drugs – clonidine
(Catapres in the USA and Dixarit in Canada) is less effective than the newer
antidepressants or gabapentin, has the advantage of coming in a patch, but does
need to be used with caution because of the effect on the blood pressure.
My recommendations? Follow
my rule of starting with the least invasive first. For women with mild or
moderate symptoms, always try the treatments in the order I have listed them
above. For women suffering moderate to severe VMS that are disrupting life,
sleep, and the ability to function, I recommend HT. Only in exceptional
circumstances do I recommend the off-label use of the other drugs. This
includes women with previous breast or uterine cancer, major blood clots
related to hormone use, chronic liver disease, or a strong preference not to
Women of today should not
suffer hot flashes. The remedies are excellent, and when it comes to HT for the
peri and early postmenopausal woman, remarkably safe. As soon as I am free of
confidentiality restraints and the new guidelines released, I will explain them
Have a great 2013.
Wulf Utian MD PhD DSc
Author; CHANGE YOUR MENOPAUSE – Why one size
does not fit all. http://www.amazon.com/Change-Your-Menopause-size-does/dp/0982845723/