Drug update: treating menopausal vasomotor symptoms without hormones.

Many menopausal symptoms don't need treatment. Up to 85% of perimenopausal women develop vasomotor symptoms such as hot flashes or sweating; perhaps half of these women find their symptoms disturbing.

Systemic hormone replacement therapy (HRT) effectively treats menopausal vasomotor symptoms, as well as vaginal dryness and urogenital atrophy associated with menopause. Many women can't or won't take HRT, however, either because they've had breast cancer or out of concern that HRT may increase their risk for breast cancer or cardiovascular disease.

What then? A variety of other systemic treatments has been documented as effective for relieving vasomotor symptoms, including low-dose regimens of antidepressant, antihypertensive, or anticonvulsant drugs. Because data on most of these treatments consist of results from only one or two small, short-term studies, some clinicians remain skeptical about the efficacy of these drugs. Limited controlled data so far suggest that mean hot flash scores (the frequency multiplied by the average severity) decline approximately 80% with systemic HRT, 60% with antidepressants, 40% with the antihypertensive drug clonidine, and 25% with placebo. Dosages of these agents often start lower than dosages used for traditional indications and then may be increased to usual dosages or remain lower. The dosage of gabapentin for hot flashes, for instance, is commonly 900 mg/day, compared with 1,800 mg/day for postherpetic neuralgia. Antidepressant dosages for hot flashes hover around the lowest dosage used to treat depression. There is little information on potential cross-tolerance between antidepressants, so if one doesn't decrease hot flashes, another drug in the same class might. For women over 70 years of age, the dosages listed below appear to be safe except for gabapentin, for which a lower starting dose may be preferable.

In addition to the options listed in the chart, women suffering from hot flashes should try to keep their surroundings cool, use loosely woven cotton clothing and bedding, and avoid triggers such as alcohol, caffeine, spicy food, or hot soups. Results from recent observational trials suggest that women who exercise regularly are less likely to have hot flashes. Results from preliminary studies of behavioral interventions suggest that taking slow, deep breaths when a hot flash is coming on may halt or diminish the flash.

Several other potential options for treating hot flashes failed to show meaningful efficacy in controlled studies. These included vitamin E, red clover, ginseng, a cream containing wild yam, and the traditional Chinese medicinal herb dong quai when used alone, without concomitant Chinese medicinal therapies. Additional controlled studies are underway using paroxetine, gabapentin, black cohosh, and red clover.

 
Drug          Dosage           Cost/Day * 
 
venlafaxine   37.5-75 mg/day   $1.55 
(Effexor)                      (75 mg) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Paroxetine    10-20 mg/day     $2.71 
(Paxil)                        (20 mg) 
 
 
 
 
 
 
 
 
 
 
fluoxetine    20 mg/day        $2.69 
 
 
 
 
 
 
 
 
 
clonidine     0.1 mg/day       $0.19 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
gabapentin    300-900 mg/day   $2.58 
(Neurontin)                    (600 mg) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
soy or soy    40-100 mg/day    $0.20 
extracts      isoflavone       (40 mg) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
black cohosh  8-100 mg b.i.d.  $0.10 
                               (40 mg) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drug          Comment ** 
 
venlafaxine   Serotonin and norepinephrine reuptake 
(Effexor)     inhibitor. Reuptake inhibitors are 
              the most recent advance for treating 
              vasomotor symptoms and may be the most 
              effective alternative to estrogen. 
              Effect of all reuptake inhibitors on 
              vasomotor symptoms seems independent 
              of antidepressant activity. Randomized, 
              double-blind trial in 180 women found 
              that 4 weeks of 75 mg/day decreased 
              median hot flash scores by 61%, 
              compared with 27% with placebo. Start 
              dosage at 37.5 mg/day for first week, 
              then increase, if needed, to 75 mg/day. 
              Effect evident within 1 week. Nausea or 
              vomiting in 10% of patients may 
              disappear after 1-2 weeks. May cause 
              dry mouth and appetite suppression. 
 
Paroxetine    Selective serotonin reuptake inhibitor. 
(Paxil)       Benefits similar to those seen with 
              venlafaxine in one controlled trial 
              and in two small, uncontrolled pilot 
              studies in breast cancer survivors. 
              Start dosage at 10 mg/day (half of a 
              20-mg tablet) for first 3 days; then 
              increase, if needed, to 20 mg/day. 
              Effect evident after 3 weeks. May 
              cause fatigue, dry mouth, nausea, 
              sexual dysfunction. 
 
fluoxetine    Selective serotonin reuptake 
              inhibitor. Seems less effective than 
              venlafaxine for hot flashes. One 
              randomized, double-blind trial in 81 
              breast cancer survivors showed a 50% 
              decrease in hot flash scores, 
              compared with 36% with placebo. May 
              cause dry mouth, nausea, sexual 
              dysfunction. 
 
clonidine     ...