I say hot flashes because that’s a more well-known term than the medical term vasomotor symptoms, which also includes night sweats. These are the heat symptoms frequently experienced by women in the menopause transition.
A previous post https://www.doctorjnazz.com/post/choosing-not-to-suffer-with-hot-flashes discussed vasomotor symptoms, why treatment has been lacking due to a study published in 2002 and what we have learned since then.
If you’re now at the point where you want to be treated for vasomotor symptoms, good for you! You’ve become empowered with hopefully good education and want to take control of your treatment.
We can break this down into two major categories: hormonal and non-hormonal.
Hormonal
What are the benefits of hormonal treatment:
Most effective at reducing vasomotor symptoms
Prevention of bone fracture
May improve mood, cosmetic symptoms (weight, hair, skin), sleep
What are the risks of hormonal treatment?
This is a loaded question despite seeming straightforward. The risks that largely drove women and prescribers away from using hormone replacement therapy were observed in women aged 65 and older. We now prescribe hormone therapy to women less than 60 years old or less than 10 years from her last period, because this is the time period shown to have fewer risks with increased benefits. So while I will present risks here, there are ways to lower these risks, age and time from last period are two of the ways we decrease risk in prescribing.
Risk of breast cancer (this was shown in the Estrogen + Progesterone arm of the WHI study, while Estrogen alone if you’ve had a hysterectomy actually decreased the risk)
Risk of blood clot in leg or lung (this can be decreased by delivering the hormone via a patch rather than an oral medication)
High cholesterol (again can be decreased with using a patch, though estrogen does increase our “good cholesterol” HDL as well)
Heart attack, stroke. I cringe to put this here because again, these were risks seen when hormones were used in women 65+. In our 50s, hormone treatment is actually protective.
Now knowing the risks, it follows that there are some people who will not be a good candidate for using hormone therapy.
Who is NOT a candidate for hormonal treatment:
Personal history of breast cancer (not including family history)
Personal history of estrogen-sensitive cancer (including uterus)
Liver disease
History of a blood clot in your leg (called a DVT, deep vein thrombosis) or lung (called a PE, pulmonary embolism)
Current smoker (increases risk of above blood clots. Over the age of 35, even birth control pills with estrogen are contraindicated in a smoker)
Non-Hormonal
Paroxetine
This is an “SSRI” or selective serotonin reuptake inhibitor, meaning serotonin is left floating in our nervous system longer. This is used to treat depression and anxiety.
Pros: If anxiety is co-existing with your hot flashes, this may be a good option.
Cons: Low libido is a classic side effect of this medication and its family members, so this may not be a good option if you are already struggling with bothersome low libido
Venlafaxine
This is an “SNRI” or selective norepinephrine reuptake inhibitor. Similar to above, this allows norepinephrine to float in our nervous system longer. It is also used for depression and anxiety.
Pros: Same as above. Plus, this is a great option if you personally have had breast cancer and you take a medication called Tamoxifen.
Cons: Same as above.
Gabapentin
This is used to increase “GABA” in our nervous system and is frequently used for neuropathy in diabetic or chemotherapy patients.
Pros: It can help with nighttime symptoms (night sweats and lack of sleep).
Cons: It can be sedating.
Fezolinetant
This is a new class of medications called Neurokinin 3 receptor antagonists.
Pros: may help with sleep
Cons: Contraindications include liver disease, taking certain other medications (ciprofloxacin, cimetidine, among others) and grapefruit juice
Coming soon: Elinzatenant, similar to the above Fezolinetant. This is in trials now.
These nuances are not known by every women’s health provider, doctor, or even ObGyn, which is why it can be difficult to find someone to properly care for you in this process. I’ve spoken about the lack of training in midlife, perimenopause and menopause care even as an ObGyn and I’m a strong advocate of injecting this training into every residency in the country.
Resources:
Some of the information contained in this article is the result of my training, medical knowledge, and personal experience without a specific source to be cited.
Menopause Practice, A Clinician’s Guide: 6th edition. The North American Menopause Society. (Now called The Menopause Society)
