Diseases

Traditionally, hot flashes have been treated with oral (by mouth) or transdermal (patch) forms of estrogen. Hormone therapy (HT), also referred to as hormone replacement therapy (HRT) or postmenopausal hormone therapy (PHT), consists of estrogens or a combination of estrogens and progesterone (progestin). Oral and transdermal estrogen are available as estrogen alone or estrogen combined with progesterone. Whether oral or transdermal, all available prescription estrogen replacement medications are effective in reducing hot flash frequency and severity. However, long-term studies (NIH-sponsored Women's Health Initiative, or WHI) of women receiving oral preparations of combined hormone therapy with both estrogen and progesterone were halted when it was discovered that these women had an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. Later studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer. Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus) in postmenopausal women who have not had their uterus surgically removed. The decision in regard to starting or continuing hormone therapy, therefore, is a very individual choice in which the patient and doctor must take into account the inherent risks and treatment benefits, plus each woman's own medical history. It is currently recommended that if hormone therapy is used, it should be used at the smallest effective dose for the shortest possible time.

The alternative treatments for menopause that have been studied in well-designed trials include phytoestrogens (plant estrogens, isoflavones), black cohosh, and vitamin E.PhytoestrogensIsoflavones are chemical compounds found in soy and other plants (such as chick peas and lentils) that are phytoestrogens, or plant-derived estrogens. Red clover is another source of isoflavones that has been used by some women in an attempt to relieve hot flashes. Isoflavones have a chemical structure that is similar to the estrogens naturally produced by the body, but their effectiveness as an estrogen has been estimated to be much lower than true estrogens.Some studies have shown that these compounds may help relieve hot flashes and other symptoms of menopause. In particular, women who have had breast cancer and do not want to take hormone therapy (HT) with estrogen sometimes use soy products for relief of menopausal symptoms. However, some phytoestrogens can actually have anti-estrogenic properties in certain situations, and the overall risks of these preparations have not yet been determined. There is some concern because of the fact that these products are selective estrogen receptor modulators (SERMs), that phytoestrogens may stimulate breast cancer growth or limit the antitumor effects of tamoxifen (Nolvadex). Data are conflicting in this regard, and it is important for women to understand that the long-term risks and potential effects of phytoestrogens have not been fully characterized. For example, researchers have shown that long-term use of phytoestrogens in postmenopausal women led to an increase in endometrial hyperplasia (overgrowth of the tissues lining the uterus) which can be a precursor to cancer.There is a perception among many women that plant estrogens are "natural" remedies and therefore safer than HT, but their safety has never been proven scientifically. Further research is needed to fully characterize the safety and potential risks of phytoestrogens.Black CohoshBlack cohosh is an herbal preparation that has been popular in Europe for hot flash relief. This herb is becoming more popular in the U.S., and the North American Menopause Society does support the short-term use of black cohosh for treating menopausal symptoms. The recommended use is up to six months because of its relatively low incidence of side effects. Some studies have shown that black cohosh can reduce hot flashes, but most of the studies have not been considered to be rigorous enough in their design to firmly prove any benefit. The Herbal Alternatives for Menopause Trial (HALT) study, a one-year study described below, failed to establish any benefit of black cohosh in the treatment of hot flashes. There have also not been scientific studies done to establish the long-term benefits and safety of this product. Research is ongoing to further determine the effectiveness and safety of black cohosh. There is some concern about the potential estrogenic effect of black cohosh on the breast, and it is not recommended as a safe therapy for women with breast cancer or who are at high risk for breast cancer.The Herbal Alternatives for Menopause Trial (HALT) was a one-year study carried out with 351 peri- or postmenopausal women experiencing hot flashes and other symptoms of menopause. The women were randomly assigned to receive one of five treatments: black cohosh alone, a multibotanical regimen that included black cohosh (and other herbal ingredients such as ginseng and dong quai), the multibotanical regimen plus dietary soy counseling, conjugated estrogen 0.625 mg (with or without medroxyprogesterone acetate), or placebo. After one year of therapy, conjugated estrogen reduced hot flashes more than placebo, but there was no significant reduction in the frequency or severity of hot flashes with black cohosh or with any of the herbal interventions when compared to placebo at any of the follow-up times.Vitamin ESome women report that vitamin E supplements can provide relief from mild hot flashes, but scientific studies are lacking to prove the effectiveness of vitamin E in relieving hot flashes. Taking a dosage greater than 400 international units (IU) of Vitamin E may not be safe, since some studies have suggested that greater dosages may be associated with cardiovascular disease risk.Other alternative therapiesThere are many supplements and substances, including ginseng; licorice; evening primrose oil; dong quai; chasteberry; and wild yam, that have been advertised as "natural" treatments for menopause. Scientific studies have not been performed to prove the safety and effectiveness of these products, although the HALT study (see black cohosh, previously) showed that ginseng and dong quai were no more effective than placebo in the treatment of hot flashes.Behavioral interventionsThe North American Menopause Society recommends that women try behavioral modifications such as attempting to keep the core body temperature cooler to help relieve hot flashes. Other modifications include regular exercise, yoga and meditation. Several studies have failed to prove a beneficial effect of exercise on hot flashes, possibly because exercise raises core body temperature and may, in fact, trigger hot flashes. Still, regular exercise has important benefits in the prevention of obesity, cardiovascular disease, diabetes, and other conditions.Relaxation therapy and stress management interventions do not appear to be effective in the management of hot flashes, according to scientific studies. However, these interventions may be beneficial for women in maintaining overall health, physical well-being, and emotional well-being during the menopausal transition.

Hot flashes are experienced by many women, but not all women undergoing menopause have this experience. A hot flash is a feeling of warmth that spreads over the body, but is often most strongly felt in the head and neck regions. Hot flashes may be accompanied by perspiration or flushing. On average, they usually last from 30 seconds to several minutes. Although the exact cause of hot flashes is not fully understood, they are thought to be due to a combination of hormonal and biochemical fluctuations brought on by declining estrogen levels. What is known is they can vary in severity, frequency, and duration. "About 70 percent of women experience hot flashes, but their underlying physiology isn't well understood," said Rebecca Thurston, an assistant professor of psychiatry, psychology, and epidemiology at the University of Pittsburgh. Sometimes hot flashes are accompanied by night sweats (episodes of drenching sweats at nighttime). This may lead to awakening and difficulty falling asleep again, resulting in unrefreshing sleep and daytime tiredness.

A few prescription medications, in addition to estrogen, can provide relief for hot flashes. While none of these drugs is as effective as estrogen, studies show that non-estrogen drugs may have up to 70% of the effectiveness of estrogen therapy when treating hot flashes.

1. Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs): This class of medication is used to treat depression and anxiety. In clinical studies, however, low doses of SSRIs and SNRIs have been shown to be effective in decreasing menopausal hot flashes. The SNRI that has been tested most extensively is venlafaxine (Effexor), although there is also evidence showing that the SSRIs paroxetine (Paxil, Paxil CR) and fluoxetine (Prozac) can be effective in controlling hot flashes.
2. Clonidine: Clonidine (Catapres) acts in the brain to decrease blood pressure. It has a long history of being used for blood pressure control, but it has potentially annoying side effects, such as dry mouth, constipation, drowsiness, or difficulty sleeping. Clonidine effectively relieves hot flashes in some women but is completely ineffective in others. Clonidine is available in pill or patch form.
3. Megestrol acetate (Megace): This medication is a type of progesterone, a female hormone. It can be effective in relieving hot flashes, but can only be taken over the short term (for several months). Serious effects can occur if the medication is abruptly discontinued, and megestrol is not usually recommended as a first-line drug to treat hot flashes. Megestrol use can also lead to weight gain.
4. Studies of another form of progesterone, medroxyprogesterone acetate (Depo-Provera), which is administered by injection, has also been useful in treating hot flashes. This drug can be used long-term but may have side effects that include weight gain and bone loss.
5. Gabapentin: Gabapentin (Neurontin) is a drug that is primarily used for the treatment of seizures that appears to be moderately effective in treating hot flashes. The drug is well tolerated by most women, but often causes drowsiness.

Nonprescription products such as herbal supplements are not controlled by the FDA because they are considered food supplements by law. Because they are not regulated like prescription medications, their ingredients and potency vary from manufacturer to manufacturer, and even from bottle to bottle from the same manufacturer. Also, careful testing and proof of safety is not required as it is with prescription medications. (The only way the FDA can recall a nonprescription product is by proving that it is dangerous.) Furthermore, there are so many nonprescription products available that a doctor cannot possibly know exactly what is in each preparation. Moreover, not one of these products has been scientifically proven to be safe or effective. So, how well have the nonprescription alternatives to hormone therapy been tested? Not one study has adhered to all of the stringent requirements that are necessary for approval of prescription medicines.

1. Specifically, sugar pills (placebos) have not been included in many studies of nonprescription alternative medications. Therefore, it is not possible to know if the product worked at all, since any effects seen with the product might have been seen with a placebo.
2. Many studies evaluated women who were taking products without supervision. Obviously, these women were aware that they were taking something to improve their symptoms. Thus, the element of objectivity was eliminated, and bias was introduced.
3. Most available studies have been carried out for only a few months. Physicians do not want to recommend a product that hasn't been proven safe over the long-term.
4. Lastly, each study seems to have a different way of judging whether the medication helps. Some analyze hot flashes alone, while others evaluate a group of symptoms without specifically segregating out hot flashes. Other studies examine multiple but individual symptoms. Even the studies that evaluate hot flashes may record different factors; the number of hot flashes per day, the severity of the hot flashes, or the duration of the hot flashes, etc.