Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Maryland. The views expressed are those of the author and not those of any government agency.
During perimenopause, most women experience hot flashes of varying frequency and intensity. When they occur more than a few times daily, or even hourly, these episodes can be quite disruptive and are often accompanied by vaginal dryness, decreased libido, forgetfulness, difficulty concentrating, and night sweats that disturb sleep.
Although estrogen and progesterone are used to treat hot flashes, the Women's Health Initiative (WHI) study found that routine use of these therapies increases some specific risks.1-3 Many women who had used estrogen for hot flashes panicked and stopped their medications abruptly, and now those who might benefit from hormone replacement therapy (HRT) are searching for alternatives. For this reason, pharmacists need to be fully aware of self-care and medical treatment options that can help women manage menopausal symptoms.
Hot flashes usually subside over a year or 2 after menopause, but in the interim, these sudden sensations of intense heat, frequently accompanied by profuse sweating and facial or body flushing, are intrusive and embarrassing. The chill that follows can be terribly uncomfortable. Stress, heavy alcohol use, and cigarette smoking seem to exacerbate hot flash frequency and intensity. Sufferers may report anxiety, irritability, or mild to severe heart palpitations. Hot flashes can be especially difficult for women who cease menstruating abruptly from chemotherapy, antiestrogen treatment for breast cancer, or surgical removal of the ovaries.4
If hot flashes are mild or infrequent, treatment is usually unnecessary. Women who suffer moderate to severe or frequent hot flashes often look for relief, and some lifestyle choices may help. Breathing exercises, for example, have been shown to reduce hot flashes and emotional symptoms significantly5,6(Table).
If hot flashes are severe and disruptive, the patient may ask for medication. Short-term HRT—at the lowest dose needed for the shortest possible time—remains the most effective treatment. The WHI study linked HRT to an increased risk of breast cancer, cardiovascular disease, stroke, venous thromboembolism, and dementia. It also confirmed estrogen's protective role in bone health.1-3
Pharmacists need to know that treatment of menopausal symptoms such as hot flashes was not a WHI end point; WHI was designed to determine if HRT prevents chronic diseases like heart disease and osteoporosis. The average age of WHI participants was 63, or about 12 years postmenopausal. Since the study was published, it has become more evident that depending on the patient's age, hormone therapy has different benefits and risks.7-11
Before menopause, estrogen?progestin birth control pills can ameliorate hot flashes and other perimenopausal symptoms by preventing fluctuating hormones. Perimenopausal women who smoke, have diabetes, or have a personal or family history of cardiovascular disease or breast cancer should avoid using estrogen for hot flash relief.12-14
Women who have an intact uterus should not take unopposed estrogen; they must also take progesterone. Unopposed estrogen increases risk of endometrial malignancy.
Interest in nonhormonal therapies is high at this time. Selective serotonin reuptake inhibitor (SSRI) antidepressant medications can reduce the number and severity of hot flashes; researchers believe their ability to inhibit serotonin reuptake may significantly reduce vasomotor symptoms of menopause. SSRIs are more likely to work if the patient's main complaints are hot flashes, irritability, or mood swings. Pharmacists need to provide the standard guidance about side effects, counsel patients to take these medications early in the day, especially if insomnia is a problem, and advise against abrupt discontinuation.15-20
Numerous studies have been conducted using clonidine, which may reduce peripheral vascular reactivity; however, many of them are older, small, or of poor design.21-25 To date, the strongest evidence of clonidine's utility is in women with tamoxifen-induced hot flashes.21,25 Because hot flashes in women with breast cancer are common and pose a management problem (estrogen therapy is contraindicated, and tamoxifen interacts with many drugs), this is an important option.
Black cohosh may reduce or prevent hot flashes, depression, and anxiety,26,27 but a large, randomized, controlled, placebo-blinded study (N = 351) could not confirm its efficacy in either premenopausal or postmenopausal women.28 (This same study found no benefit in soy supplements.) Although most of this herb's side effects are mild and transient (gastrointestinal upset or rash), numerous studies and case reports have documented black cohosh's rare but potential hepatotoxicity, which can cause death.29-33
Researchers recently have had encouraging preliminary results with 49 g of crushed flaxseed daily in a small study (N = 30) of perimenopausal women, noting reductions of >50% in hot flash severity and frequency. Mild or moderate abdominal distention was common, as was mild diarrhea. This dietary therapy needs more study to determine if it is more effective than placebo.34
Although the number of alternative treatments for hot flashes is increasing, hormonal therapies are still the most effective. Pharmacists need to be familiar with the risks and benefits of hormonal and nonhormonal therapies and aware of the OTC products women may use to find relief.
Clear communication about treatment risks and benefits, individualization of treatment to meet patient needs and beliefs, and careful follow-up can help women find potentially effective therapy. The good news: Since the WHI results were published, researchers have documented a significant decrease in prescriptions for HRT, but a significantly higher percentage of prescription filling. This seems to mean that women who choose HRT do so with greater certainty in their choice.35
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