Hot Flashes: What Are the Alternatives?

Sue Holmes, RN, a breast health coordinator at the deNicola Breast Health Center in Nashua, New Hampshire, was diagnosed at 54 with estrogen receptor-positive noninvasive breast cancer seven years after starting hormone replacement therapy, or HRT, for her symptoms of menopause. “Everybody was taking HRT, then the pendulum swung the other way, and nobody was taking HRT.”

After her diagnosis, Holmes was immediately taken off HRT and her menopausal symptoms returned with a vengeance. “It seemed even worse than I remembered it,” Holmes says. “I was miserable, absolutely miserable. I had terrible hot flashes. I couldn’t think, I couldn’t sleep at night. It was not a good way to live.”

After the Women’s Health Initiative, a large study that examined the effects of combined estrogen and progestin, showed HRT increased the risk of breast cancer, survivors were told to abandon their pills to prevent recurrence. But with few alternatives to combat hot flashes, many survivors feel they must decide between risk of recurrence and quality of life.

Charles Loprinzi, MD, a medical oncologist at Mayo Clinic Cancer Center in Rochester, Minnesota, and a member of the North American Menopause Society, says it doesn’t have to be an either-or decision. While other treatments may not be as effective as HRT, researchers are actively looking at other possibilities to find what works and what doesn’t. Here’s what they’ve found.

Studies have shown two types of antidepressants—selective serotonin reuptake inhibitors, or SSRIs, and serotonin-norepinephrine reuptake inhibitors, or SNRIs— can reduce the severity and frequency of hot flashes. Effexor (venlafaxine), an SNRI, has the least interference with tamoxifen and has shown effectiveness for hot flashes, decreasing the symptom by 60 percent in more than half of women with hot flashes compared with placebo.

Paxil (paroxetine), an SSRI, decreases hot flashes by up to 70 percent, but new studies show Paxil may interfere with the activity of tamoxifen in some women. Zoloft (sertraline) and Prozac (fluoxetine), also SSRIs, have shown benefit, but not as much as the other antidepressants.

While Neurontin (gabapentin) is marketed as an antiseizure medication, there are several published placebo-controlled trials that have found it can reduce hot flashes by half. Additional data demonstrate a high dose of the drug might reduce hot flashes a bit more. Dr. Loprinzi recently completed a study of Neurontin to combat hot flashes in prostate cancer patients, and found hot flashes were reduced by almost half compared with about 25 percent reduction with placebo.

A clinical trial looking at vitamin E and the frequency of hot flashes showed a slight positive effect, says Dr. Loprinzi. Soy and black cohosh have anecdotal evidence as a treatment for hot flashes, but more definitive trials demonstrate that these agents do not appear to be any better than placebo. Because some natural remedies also have potential phytoestrogenic properties (estrogen-like properties seen in natural plant compounds), some physicians advise caution to survivors considering taking large doses for hot flashes.

Acupuncture has been widely studied, but a Mayo Clinic study published early this year found no additional benefit of acupuncture compared with placebo. Several clinical trials for hot flashes involving acupuncture and other integrative therapies in breast cancer survivors are currently ongoing.

Breast cancer survivors have numerous non-HRT options to treat hot flashes, but it may take time to find the single or combination therapy that works best, says Dr. Loprinzi.

Holmes, who tried vitamin E, antidepressants, black cohosh, and other remedies, says they either didn’t work or she developed side effects. Because her cancer was non-invasive, her doctor prescribed a very small dose of estrogen in addition to small doses of progestin delivered directly to the uterus through an intrauterine device to relieve her hot flashes, a regimen that has been studied fairly recently.

Holmes understands she’s taking a risk, but says it’s one she made based on her individual history. “If I had had invasive breast cancer, would I do it? I’m not sure. But I still think you’ve got to balance quality of life with your situation.”

Molly Lindell, on the other hand, a three-year survivor of invasive breast cancer, went cold turkey after her diagnosis in 2004. She worked with her doctor to find the right drug combination to decrease her severe hot flashes. When the first two antidepressants she tried failed to reduce her symptoms, her doctor recommended another SSRI and a benzodiazepine, an older class of antidepressant, along with Neurontin.