Table 1.
Treatment options for menopausal hot flashes
| Nature of therapy | Benefits on hot flashes | Current status | Comments |
|---|---|---|---|
| Transdermal estrogen + micronized progestin or oral estrogen + micronized progestin | Definite | 1st choice therapy for Rx of moderate to severe hot flashes in women with intact uterus Transdermal preparation has lower risk of thromboembolism, vaginal bleeding, stroke, and breast tenderness and lacks hepatic first pass metabolism |
Past history of stroke/breast cancer/venous thromboembolic event, coronary artery disease, active liver disease, unexplained vaginal bleeding, active gall bladder disease |
| Transdermal/oral estrogen alone | Definite | 1st choice therapy for Rx of moderate to severe hot flashes in women without uterus Transdermal preparation has lower risk of thromboembolism, vaginal bleeding, stroke, and breast tenderness and lacks hepatic first pass metabolism |
Same as above |
| SSRIs (paroxetine and escitalopram) | Definite | Rx of moderate to severe hot flashes in women who cannot tolerate hormonal therapy or in whom hormonal therapy is contraindicated | Paroxetine should be avoided in women on tamoxifen |
| SNRIs | Definite | Rx of moderate to severe hot flashes in women who cannot tolerate hormonal therapy or in whom hormonal therapy is contraindicated SNRIs are equally effective to SSRIs |
May be used as alternative treatment option for women who cannot tolerate SSRIs/who develop intolerable side effects to SSRIs |
| Gabapentin | Definite | Useful in women with predominantly nocturnal moderate to severe hot flashes | Sedation is main side effect |
| 500 mg intramuscular dose of depot medroxyprogesterone acetate once every few months | Definite | More effective than venlafaxine | May be used in women who have contraindications to estrogen therapy |
| Tibolone | Definite | A synthetic steroid widely used in Europe, it controls hot flashes and has beneficial effect on bone metabolism | Associated with higher risk of stroke |
| Conjugated estrogen+bazedoxifene | Studies are needed | Theoretically, this combination has agonist effect on bone, antagonist effect on endometrium and no effect on breast | |
| Oral contraceptive pills | Definite | May be used in perimenopausal women in (40-50 years of age) who desire contraception and have heavy bleeding | Past history of stroke/breast cancer/venous thromboembolic event, coronary artery disease, active liver disease, unexplained vaginal bleeding, active gall bladder disease |
| Cognitive behavior therapy | Benefits distress and sleep problems, but effects on hot flashes per se is not certain | Often used without any proven benefit | |
| Stellate ganglion block | Beneficial in some trials | Future studies are needed before this procedure can be used routinely | |
| Weight loss | Some benefits in overweight patients | Must be tried in obese postmenopausal women with hot flashes | |
| Exercise | Uncertain | May trigger hot flashes through elevation of core body temperature | |
| Plant based therapies (soybean, chickpeas, lentils for isoflavones; flaxseed, lentils, grains, fruits, and vegetables for lignans) | Uncertain | Concern of risk of breast cancer | |
| Flaxseed/evening primrose oil | Nil | Not recommended | |
| Acupuncture | Benefits hot flashes, sleep problems, sweating, emotional and physical symptoms | One randomized controlled trail (n=70) showed definite benefit for acupuncture in menopausal hot flashes | Future trails will delineate it role in a better manner |
SSRIs: Selective serotonin reuptake inhibitors, SNRIs: Selective norepinephrine reuptake inhibitors