New Treatments for Hot Flushes
July 23rd, 2007
Most women approaching the menopause will have hot flushes. For those for whom this inconvenient symptom becomes persistent and severe, there is need for some treatment which will improve the quality of their life. Hot flushes are not restricted to postmenopausal women as women who have breast cancer are often given drugs which block the action of oestrogen. Even men with prostate cancer given anti androgen treatment, often complain of hot flushes.
The cause of hot flushes is not well understood. Women with hot flushes have an increased internal temperature and a reduced zone between shivering and sweating, the thermo neutral zone. This is a common observation with women complaining of feeling cold and shivering one moment and then complaining of feeling hot. It is not oestrogen deficiency which leads to these changes but fluctuating oestrogen concentrations. Most hot flushes resolve with time.
There are some factors that predispose to hot flushes and they include a late perimenopause, African-American race, obesity, lack of exercise and smoking. Oestrogen treatment works in most women, but if given to a woman who still has a womb, it must be accompanied by progesterone. Progesterone alone is also highly effective, reducing hot flushes by 80%, and can sometimes be given if a woman is not allowed to take oestrogen.
However oestrogen taken with progestogen has shown in several recent large studies to be associated with an increased risk of heart disease, thromboembolic disease, stroke and breast cancer. Of the other treatment often recommended for hot flushes, gabapentin, paroxetine, venlafaxine, citalopram, clonidine, red clover isoflavones and soy isoflavones have all been studied in proper clinical trials. Given that the placebo effect for hot flush treatments can be as high as 50%, it is also not surprising to note that a large number of natural complementary remedies, many of them with week oestrogen like properties, are believed to be effective. If one looks at the data from clinical trials objectively, it’s clear that red clover and soy isoflavones are associated with little if any reduction in the number of hot flushes per day. The same is true of many antidepressants and clonidine; these treatments are also associated with numerous side-effects. Of the nonoestrogenic drugs, venlafaxine is more effective than clonidine and gabapentin is also effective.
However it is clear that oestrogen or progestogen or both in combination are the most effective in alleviating the symptom and small doses of these hormones are now being trialled in the hope that the known side-effects of heart disease, breast cancer and thrombosis become negligible.
The American College of Obstetricians and Gynaecologists have recommended that women with mild vasomotor symptoms consider lifestyle modification with non-prescription remedies even though the benefit is believed to be small. Hormonal interventions should be considered unless there are contraindications to oestrogen when progestogens, venlafaxine, paroxetine, fluoxetine or gabapentin should be considered.
London Medical is active in Women’s Health and we have clinics for routine checkups, cervical smears, osteoporosis assessment and treatment, sexual health and vaccination against cervical cancer, and gynaecological concerns.
Dr Ralph Abraham, July 2007
Ref: Clinical update: new treatments for hot flushes. Lancet 2007; 369, 2062-4
