In 2002, the Women's Health Initiative began to see evidence that post-menopausal hormone therapy increased the risk of stroke and other health problems. As a result, millions of women stopped taking the pills. (The pills studied included an estrogen-progestin combination or estrogen alone.) This meant that many women would now have to put up with more discomfort from menopause-related symptoms, including hot flashes.
And the data since then suggest that most women are doing just that. A survey from the Endocrine Society (an international organization for doctors and scientists who study hormone science) showed that 72% of women with menopause symptoms don't get treatment. And 77% have not discussed their symptoms with health care providers. (The survey included 810 U.S. women ages 45–60. It was done in April 2012.)
These survey data may not be surprising if menopause is understood as part of the normal aging process. In that sense, it does not need "treatment" per se.
But women who have difficulty managing menopause symptoms want relief. And, in the United States, more than a million women reach menopause every year. Given the cautions about hormone therapy, it's not surprising that the antidepressant option has become an important alternative to manage bothersome symptoms.
Hot flashes are discharges of body heat that come as a woman is moving through and beyond the transition to menopause. The feeling is sudden and intense. The hot, flushing feeling is mostly in the upper body and face. A woman may have uncomfortable sensations before the heat starts — her heart may beat faster; she may feel nauseated or dizzy; she may experience a headache.
It's not clear why it happens. It is no doubt a consequence of hormonal changes. One theory is that these changes make it harder for the brain to monitor and control the body's own thermostat. The brain may mistakenly detect overheating and trigger a sudden release of heat to cool the body down. Some women actually experience chills at the end of a hot flash.
As many as 85% of women experience hot flashes around the menopause transition. Hot flashes can begin and end in as little as 6 months. For some women, hot flashes can occur over the course of a decade or more. About 2 years is the average.
How often they occur also varies. Some women have just occasional bouts, while other have 20 or more episodes per day.
Interestingly, the problem is not confined to women — men can have them too. Hot flashes can occur if male hormone levels drop, for example, in response to treatment for prostate cancer.
For many years, researchers have studied the use of antidepressants to ease hot flashes. Some researchers noticed that women in menopause being treated for mood and anxiety problems reported some relief from their symptoms as a bonus.
The studies have had mixed results. Partly it was difficult for researchers to tease out how the drugs affected hot flashes because participants were very different. Some women had medical or psychiatric problems that could influence symptoms, while others did not. Also, the studies looked at different antidepressants and they didn't all use the same definitions and measures of hot flashes.
Two small but encouraging studies led Philadelphia researchers to study the selective serotonin reuptake inhibitor (SSRI) escitalopram (Lexapro) to see if it might reduce the frequency, severity and discomfort of hot flashes. They randomly assigned 205 healthy menopausal women who had at least 28 troubling or severe episodes per week to take either a 10-milligram escitalopram pill or a placebo daily. If the frequency of a woman's hot flashes didn't drop by at least half after 4 weeks, or if there was no decrease in their severity, the dose was doubled. Treatment stopped after 8 weeks.
At the start of the trial, women experienced 9.78 hot flashes a day on average. After 8 weeks, that number had dropped to 5.26 for women taking the drug, versus 6.43 for women taking the placebo pill. Escitalopram also significantly reduced the severity and bother associated with hot flashes compared with a placebo. Once treatment stopped, the frequency of hot flashes increased significantly among the women who took the drug, but not in those who took the placebo, an additional sign of the drug's effectiveness.
The research is not limited to escitalopram. Another SSRI, paroxetine (Paxil), has probably been studied the most. A new brand of paroxetine (called Brisdelle) got approved by the U.S. Food and Drug Administration in 2013. This branding is a marketing tactic — generic paroxetine is just as effective.
Researchers at Massachusetts General Hospital in Boston looked at the antidepressant duloxetine (Cymbalta). This study showed that depressed women being treated with duloxetine saw an improvement of menopause symptoms, including hot flashes.
And a drug that is not an antidepressant — the antiseizure drug, gabapentin (Neurontin) — also may reduce hot flashes.
In the last couple of years, women's health experts have reexamined recommendations about hormone therapy (HT). They still tend to agree that it should be avoided for treating chronic conditions. Generally speaking, the risks are still too great for most women to use this treatment indefinitely.
But it is still the most effective approach for managing the transitional discomforts of menopause. So, if symptoms are not responding to other therapies, it's reasonable to consider HT for a limited time to ease the transition. Doctors may be especially inclined to recommend HT if hot flashes or night sweats are interfering with sleep and daily functioning.
Regarding hormone therapy, the North American Menopause Society and the American Congress of Obstetricians and Gynecologists recommend taking the smallest effective dose for the shortest possible time. The best time to start HT, when there is the least evidence of long-term harm, is right after menopause begins. Risk goes up the later one starts or the longer one uses HT. For example, the risk of breast cancer goes up after 5 years of therapy.
Certainly discuss with your doctor the timing and duration of any treatment. You should understand any risks and benefits that may be specific to your situation before starting HT.
Of course, not all approaches to hot flashes involve hormones or drugs. Consider these simple, practical recommendations for feeling cooler:
- Keep the thermostat down.
- Make sure bedding is light (especially if you're prone to get hot flashes at night).
- Dress in layers, so you have a layer to take off when a hot flash comes on.
Some research indicates that lifestyle changes, such as losing weight or eating a low-fat diet, may help. You can try to avoid caffeine, alcohol and smoking. Some experts recommend vigorous exercise. All of these may decrease the frequency or intensity of hot flashes.
But it is always good to know you have options. Do discuss them with your doctor.
If you are bothered by hot flashes and are not a candidate for hormone therapy, then it's worth considering taking an antidepressant. These drugs don't appear to completely eliminate hot flashes in most women, but they may make the symptoms more tolerable. An antidepressant may be particularly helpful for women who are also having a problem with anxiety, irritability or low mood.
Michael Craig Miller, M.D. is the former editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 30 years.
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